RECOMMENDATIONS FOR USING OPIOIDS
IN CHRONIC NON-CANCER PAIN
E. Kalso, L. Allan, P. L. I. Dellemijn, C. C. Faura, W. K. Ilias, T. S. Jensen, S. Perrot, L. H. Plaghki, M. Zenz
the need for guidelines for non-cancer pain
•Strong opioids have an established role in cancer
pain and in palliative care settings.
Their use in cancer pain has been demonstrated
in guidelines such as the WHO ladder
However, physicians in many countries are still
relatively unfamiliar with using opioids for the
treatment of chronic, non-cancer pain.
Guidance is therefore needed about their use.
1 and the
The ‘Amsterdam Recommendations’ Group
The group is:
• multidisciplinary, with experts in:
• cover the use of opioids in all types of chronic
•are based on the best available evidence from
randomised trials wherever possible
• recognise that the full range of opioids is not
uniformly available throughout Europe
• do not specify particular formulations
• aim to provide a framework for the development
of national or local guidelines.
1. The management of chronic pain should be
directed by the underlying cause of the pain.
Whatever the cause, the primary goal of patient
care should be symptom control.
*The ‘Amsterdam Recommendations Group’ comprises:
Eija Kalso Helsinki University Central Hospital, Finland
Laurie AllanNorthwick Park Hospital and St Mark’s NHS Trust,
Harrow, Middlesex, UK
Paul L I DellemijnMáxima Medical Center, Veldhoven, The Netherlands
Clara C FauraInstituto de Neurociencias,
Universidad Miguel Hernández-CSIC, Alicante, Spain
Wilfried K IliasHospital of the Hospitaller Order of St John of God,
Troels S JensenAarhus University Hospital, Aarhus, Denmark
Serge PerrotHospital Tarnier, Paris, France
Leon H PlaghkiCliniques Universitaires St Luc, Brussels, Belgium
Michael Zenz Bochum University Hospital Bergmannsheil and
Knappschaftskrankenhaus Bochum, Germany
The original meeting was supported by an educational grant from
Poster presented at 4th Congress of European Federation of IASP Chapters
(EFIC), Prague, 2–6 September 2003
Pain specialists should be familiar with the
‘Amsterdam recommendations’, and we hope
that these recommendations will form the
basis for discussion by other groups, and for
the development of appropriate national or
regional guidelines about the use of opioids
to treat chronic non-cancer pain.
3. The aim of opioid treatment is to relieve pain and
improve the patient’s Quality of Life. Both of these
should be assessed during a trial period.
• The maximum length of the trial period
(e.g. 3–4 months) should be agreed by the
physician and the patient.
2. Opioid treatment should be considered for both
continuous neuropathic and nociceptive pain if
other reasonable therapies fail to provide adequate
analgesia within a reasonable timeframe.
• Strong opioids should not be used as
monotherapy, but in the context of an
interdisciplinary and multimodal approach.
4. The prescribing physician should be familiar with
the patient’s psychosocial status.
• It may be helpful to involve a psychologist or
• Patients with a history of drug or alcohol abuse
should be referred to a multidisciplinary pain
5. The use of sustained-release opioids administered
at regular intervals is recommended.
• As a rule, short-acting opioids should be
avoided. In cases of breakthrough pain the use
of short-acting opioids should be considered
6. Treatment should be monitored.
• Thorough monitoring includes:
- pain relief
- adverse effects
- functional status
- Quality of Life.
7. A contract setting out the patient’s rights and
responsibilities may help to emphasise the
importance of patient involvement.
• Patients have the right to be fully informed
about the nature of chronic opioid treatment.
• Agreeing a contract also shows that the patient
is committed to the aims of the treatment.
8. Opioid treatment of chronic pain should not be
considered a lifelong treatment.
• Treatment may be stopped or the dose reduced:
- if the patient experiences a significant
improvement in the underlying condition
- if intolerable adverse effects occur
- if the patient does not comply with the
1. Stjernsward J. WHO cancer pain relief programme. Cancer Surveys 1998,
2 Hanks GW et al. Morphine and alternative opiods in cancer pain: the EAPC
recommendations. Br J Cancer, 2001, 84:587-593