Recommendations for using opioids in chronic non-cancer pain

Article (PDF Available)inEuropean Journal of Pain 7(5):381-6 · February 2003with61 Reads
DOI: 10.1016/S1090-3801(02)00143-X · Source: PubMed
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. 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. 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. 4. The prescribing physician should be familiar with the patient's psychosocial status. 5. The use of sustained-release opioids administered at regular intervals is recommended. 6. Treatment should be monitored. 7. A contract setting out the patient's rights and responsibilities may help to emphasize the importance of patient involvement. 8. Opioid treatment should not be considered a lifelong treatment.
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
and the
EAPC guidelines
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.
The ‘Amsterdam Recommendations’ Group
The group is:
multidisciplinary, with experts in:
- anaesthesiology
- neurology
- pharmacology
- rheumatology.
The recommendations:
cover the use of opioids in all types of chronic
non-cancer pain
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 Allan Northwick Park Hospital and St Mark’s NHS Trust,
Harrow, Middlesex, UK
Paul L I Dellemijn Máxima Medical Center, Veldhoven, The Netherlands
Clara C Faura Instituto de Neurociencias,
Universidad Miguel Hernández-CSIC, Alicante, Spain
Wilfried K Ilias Hospital of the Hospitaller Order of St John of God,
Vienna, Austria
Troels S Jensen Aarhus University Hospital, Aarhus, Denmark
Serge Perrot Hospital Tarnier, Paris, France
Leon H Plaghki Cliniques 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,
2Hanks GW
et al.
Morphine and alternative opiods in cancer pain: the EAPC
recommendations. Br J Cancer, 2001, 84:587-593
    • "Rather than reflecting previously untreated chronic pain, these patterns may reflect a wider change in the general approach to prescribing for pain [5, 16]. The therapeutic benefit of opioids in musculoskeletal pain is established for short but not long term use [8, 10, 12] whilst evidence is accumulating on harms, most commonly physical dependence, tolerance, addiction and adverse effects [8,1718192021. Many people with chronic pain report difficulties with prescribed opioids, including psychosocial problems and concerns about controlling their medication use [22]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. Methods We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. Results Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs’ responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient’s wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. Conclusions Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients.
    Full-text · Article · Sep 2015
    • "The problem of poorly controlled pain is still considerable: in Europe 19% of adults suffer from continuous pain that seriously compromises the quality of their emotional, social, and working life [1]. Opioids represent an important option for pain management; while there is agreement on their use in acute and cancer pain, long-term use for noncancer chronic pain remains controversial [2]. Indeed, some patients benefit from such treatment in terms of pain reduction and improvement in quality of life, while others do not [3]. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective. Opioid therapy in patients with chronic noncancer pain must be preceded by evaluation of the risk of opioid misuse. The aim of this study was to evaluate the predictive validity of the Italian translation of the Pain Medication Questionnaire (PMQ) and of the Diagnosis Intractability Risk and Efficacy Score (DIRE) in chronic pain patients. Design. 75 chronic noncancer pain patients treated with opioids were enrolled and followed longitudinally. Risk of opioid misuse was evaluated through PMQ, DIRE, and the physician's clinical evaluation. Pain experience and psychological characteristics were assessed through specific self-report instruments. At follow-ups, pain intensity, aberrant drug behaviors, and presence of the prescribed opioid and of illegal substances in urine were also checked. Results. PMQ demonstrated good internal consistency (Cronbach's α = 0.77) and test-retest reliability (r = 0.86). Significant correlations were found between higher PMQ scores and the number of aberrant drug behaviors detected at 2-, 4-, and 6-month follow-ups (P < 0.01). Also the DIRE demonstrated good predictive validity. Conclusions. The results obtained with specific tools are more reliable than the clinician's evaluation alone in predicting the risk of opioid misuse; regular monitoring and psychological intervention will contribute to improving compliance and outcome of long-term opioid use.
    Full-text · Article · Aug 2014
    • "Strong centrally acting analgesics (e.g., opioids) are gaining acceptance for use in the management of non-malignant, chronic pain [1–3]. In addition to relieving pain, goals of long-term analgesic therapy are to allow patients to maintain their independence and stay active [4]. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Strong centrally acting analgesics, including tapentadol prolonged release (PR), have demonstrated efficacy for the management of non-malignant, chronic pain. Maintaining patient independence, including the ability to drive safely, is a key goal of long-term analgesic therapy. This multicenter, open-label, phase 3b trial evaluated the effects of tapentadol PR on driving ability. Methods: This study included patients who had completed previous tapentadol PR trials for severe low back or osteoarthritis pain. After at least 6 weeks of dose stability, patients continued taking tapentadol PR (50-250 mg twice daily) and could take supplemental immediate-release tapentadol 50 mg, except on the day before or day of the driving test (before the test). Pain intensity was assessed using an 11-point numerical rating scale. The Vienna Test System-Traffic Plus was used to assess cognitive and psychomotor function. The key surrogate parameter for driving ability was a global judgment based on 6 battery tests. Results: Thirty-eight patients enrolled and completed the trial, and 35 patients completed all 6 tests. Pain scores remained unchanged from enrollment to final visit [mean (standard deviation) change, -0.2 (1.0)]. Approximately two-thirds [65.7% (23/35)] of patients were classified as fit to drive based on the global judgment of driving-specific ability [34.3% (12/35) not fit to drive]. Total daily tapentadol PR dose (>200 vs. ≤200 mg/day) did not affect global judgment of driving ability (P = 0.4885). Two adverse events (considered unrelated to study drug) were reported. Conclusion: Results suggest that most patients receiving a stable dose of tapentadol PR for severe, chronic pain would be able to drive, consistent with earlier studies evaluating stable treatment with strong opioids. Study design limitations and needs for individual patient assessment must be considered in clinical practice.
    Article · Jun 2014
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