New guideline for prescribing opioid pain drugs published

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New guideline for prescribing opioid pain drugs published

http://www.eurekalert.org/pub_releases/2009-02/ohs-ngf020609.php

Researchers at Oregon Health & Science University provide evidence to

support first published guideline for treating chronic non-cancer

pain with opioid medications

A national panel of pain management experts representing the American

Pain Society (APS) and the American Academy of Pain Medicine (AAPM)

has published the first comprehensive, evidence-based clinical

practice guideline to assist clinicians in prescribing potent opioid

pain medications for patients with chronic non-cancer pain. The long-

awaited guideline appears in the current issue of The Journal of

Pain, www.jpain.org.

To create this guideline, researchers in the Oregon Evidence-based

Practice Center (EPC) at Oregon Health & Science University

collaborated with the APS and AAPM for two years, reviewing more than

8,000 published abstracts and nonpublished studies to assess clinical

evidence on which the new recommendations are based.

" This guideline was a true multidisciplinary effort that sought to

address in a balanced manner the many challenging issues that

clinicians face with regard to when and how to prescribe opioids for

chronic noncancer pain, " said Chou, M.D., principal

investigator; director of the American Pain Society Clinical Practice

Guidelines Program; scientific director of the Oregon Evidence-Based

Practice Center at OHSU; and associate professor of medical

informatics and clinical epidemiology, and medicine (general internal

medicine and geriatrics) in the OHSU School of Medicine.

" A key part of this process was performing a comprehensive literature

review to inform the recommendations — though an important take-home

message is that even though the recommendations represent the best

judgment of the panel based on the currently available literature,

there is still a lot of research that needs to be done. "

The expert panel concluded that opioid pain medications are safe and

effective for carefully selected, well-monitored patients with

chronic non-cancer pain. They made 25 specific recommendations and

achieved unanimous consensus on nearly all.

Opioid prescribing has increased significantly due to growing

professional acceptance that the drugs can relieve chronic non-cancer

pain, and the guideline acknowledges there are widespread concerns

about increases in prescription opioid abuse, addiction and

diversion.

Opioids, such as morphine, oxycodone, oxymorphone and fentanyl are

potent analgesics. They traditionally have been used to relieve pain

following surgery, from cancer and at the end of life. Today opioids

are used widely to relieve severe pain caused by chronic low-back

injury, accident trauma, crippling arthritis, sickle cell,

fibromyalgia, and other painful conditions.

Prior to initiating chronic opioid therapy, the guideline advises

clinicians to determine if the pain can be treated with other

medications. If opioids are appropriate, the clinician should conduct

a thorough medical history and examination and assess potential risk

for substance abuse, misuse or addiction.

Diligent Patient Monitoring Is Essential

A key recommendation urges clinicians to continuously assess patients

on chronic opioid therapy by monitoring pain intensity, level of

functioning and adherence to prescribed treatments. Periodic drug

screens should be ordered for patients at risk for aberrant drug

behavior.

Other recommendations in the APS/AAPM clinical practice guideline

include:

Methadone: Use of methadone for pain management has increased

dramatically but few trials have evaluated its benefits and harms for

treatment of chronic non-cancer pain. Methadone, therefore, should be

started at low doses and titrated slowly. Because of its long half-

life and variable pharmacokinetics, the panel recommends methadone

not be used to treat breakthrough pain or as an as-needed medication.

Abusers: Chronic opioid therapy must be discontinued in patients

known to be diverting their medication or in those engaging in

serious aberrant behaviors.

Breakthrough Pain: As-needed opioids can be prescribed based on

initial and ongoing analysis of therapeutic benefit versus risk.

High Doses: Patients who need high doses of opioids (200 mg daily of

morphine or equivalent) should be evaluated for adverse events on an

ongoing basis, and clinicians should consider rotating pain

medications when patients experience intolerable side effects or

inadequate benefit despite appropriate dose increases.

Driving and Work Safety: Patients should be educated about the

greater risk for impairment when starting chronic opioid therapy and

counseled not to drive or engage in potentially dangerous work if

impaired.

Pregnancy: Clinicians should counsel women about risks of opioids in

pregnancy and encourage minimal or no use of chronic opioid therapy

unless potential benefits outweigh risks.

The guideline on opioid therapy for chronic non-cancer pain is the

first such collaboration between APS and AAPM. It is the sixth

evidenced-based, pain management clinical practice guideline

published by APS. Others have covered sickle-cell disease, arthritis,

cancer, fibromyalgia, and low back pain.