Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

Oregon Evidence-based Practice Center, Department of Medicine, Department of Medical Informatics and Clinical Epidemiology, Oregon Health and Science University, Portland, Oregon, USA.
The journal of pain: official journal of the American Pain Society (Impact Factor: 4.01). 03/2009; 10(2):113-30. DOI: 10.1016/j.jpain.2008.10.008
Source: PubMed


Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. PERSPECTIVE: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

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    • "Participants met eligibility criteria if they had a diagnosable chronic pain condition, had been prescribed long-term analgesic pharmacotherapy (for at least 90 days, see clinical guidelines presented in Chou et al., 2009), and had taken opioids daily or nearly every day (≥ 5 days/week) for >3 months. Participants were recruited from primary care clinics, pain clinics, and neurology clinics in Tallahassee, FL via flyers and online classified ads. "
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    • "An unfortunate feature of opioid medications in general is that with repeated administration, tolerance may develop to the analgesic effect resulting in a need to increase dosing to maintain the desired effect in a significant percent of cases. Unfortunately, until the availability of Zohydro ER ® , none of the formulations of hydrocodone provided a means to deliver medication over a sustained period of time, which is intuitively preferred for optimum management of chronic pain [25] [26] (but see [7] [27] [28] for reviews). For these reasons, the new formulation of hydrocodone appeared attractive because there would now be an extended-release capsule with a dose option that could provide the desired, sustained, analgesic effect with fewer pills that did not contain an add-on drug to reduce safety. "
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    ABSTRACT: Recently, the U.S. Food and Drug Administration (FDA) approved Zohydro®, an extended release formulation of the opioid analgesic hydrocodone that contains no acetaminophen. This approval was against the recommendation of the FDA's Expert Panel. Subsequently, both chronic pain advocates and anti-drug abuse advocates have steadfastly expressed their support of, or astonishment at this decision. Here, we review the pharmacokinetics, pharmacodynamics, safety and abuse liability of this hydrocodone formulation and how it relates to Expert Panel's opinion and the FDA decision. We discuss the important issues, risk mitigation, potential use of abuse deterrents, and how the different viewpoints of the Expert Panel and FDA decision makers resulted in the approval and subsequent controversy.
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    • "In a recent systematic review of opioid guidelines,24 13 protocols met the selection criteria, and of these, two were considered to be of the highest quality. These were the American Pain Society/American Academy of Pain Medicine “Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain”25 and the “Canadian guideline for safe and effective use of opioids for chronic non-cancer pain”.26 The majority of recommendations from all the guidelines were based on expert consensus opinion or observational data. "
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