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| A) | the highest safe dose. | ||
| B) | extended-release opioids. | ||
| C) | a quantity no greater than that needed for the expected duration of severe pain. | ||
| D) | All of the above |
Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute (less than one month) or subacute (one to three months) pain, clinicians should prescribe the lowest effective dose of immediate-release opioids in a quantity no greater than that needed for the expected duration of severe pain [2,4].
| A) | Opioid therapy for chronic pain should be presented as a trial for a pre-defined period. | ||
| B) | The goals of treatment should be established with all patients prior to the initiation of opioid therapy. | ||
| C) | Opioids should not be combined with nonpharmacologic and nonopioid pharmacologic therapy. | ||
| D) | The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies. |
If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate. Clinicians should consider opioid therapy only if expected benefits for pain and function are anticipated to outweigh risks to the patient [2,4].
Opioid therapy for chronic pain should be presented as a trial for a pre-defined period (e.g., ≤30 days). The goals of treatment should be established with all patients prior to the initiation of opioid therapy, including reasonable improvements in pain, function, depression, anxiety, and avoidance of unnecessary or excessive medication use [2,9]. The treatment plan should describe therapy selection, measures of progress, and other diagnostic evaluations, consultations, referrals, and therapies.
In patients who are opioid-naïve, start at the lowest possible dose and titrate to effect. Dosages for patients who are opioid-tolerant should always be individualized and titrated by efficacy and tolerability [2,9]. When starting opioid therapy for chronic pain, clinicians should prescribe short-acting instead of extended-release/long-acting (ER/LA) opioid formulations [2,4].
| A) | Unlike nonopioids, opioids do not have a ceiling effect. | ||
| B) | Opioid side effects do not occur in patients at the end of life. | ||
| C) | Nonopioid pharmacotherapy is more difficult to administer to patients. | ||
| D) | Opioids are generally more acceptable to patients and their families than nonopioid options. |
Strong opioids are used for severe pain at the end of life [13,14]. Morphine, buprenorphine, oxycodone, hydromorphone, fentanyl, and methadone are the most widely used in the United States [19]. Unlike nonopioids, opioids do not have a ceiling effect, and the dose can be titrated until pain is relieved or side effects become unmanageable. Patients who are opioid-naïve or who have been receiving low doses of a weak opioid, the initial dose should be low, and, if pain persists, the dose may be titrated up daily until pain is controlled.
| A) | Oral | ||
| B) | Parenteral | ||
| C) | Transdermal | ||
| D) | Intramuscular |
More than one route of opioid administration will be needed by many patients during end-of-life care, but in general, opioids should be given orally, as this route is the most convenient and least expensive. The transdermal route is preferred to the parenteral route, although dosing with a transdermal patch is less flexible and so may not be appropriate for patients with unstable pain [14]. Intramuscular injections should be avoided because injections are painful, drug absorption is unreliable, and the time to peak concentration is long [14].
| A) | Hospital inpatients | ||
| B) | Those with sickle cell disease | ||
| C) | Persons receiving end-of-life care | ||
| D) | Adults (18 years of age and older) |
The 2022 clinical practice guideline includes 12 recommendations for clinicians who are prescribing opioids for outpatients 18 years of age or older with acute (duration <1 month) pain, subacute (duration of 1 to 3 months) pain, or chronic (duration of >3 months) pain outside of sickle cell disease related pain management, cancer pain treatment, palliative care, and end-of-life care. These recommendations are graded according to applicability and strength of the supporting evidence (Table 1).
| A) | Inclusion of opioids in every chronic pain treatment plan | ||
| B) | Strict adherence to established opioid prescribing guidelines | ||
| C) | Flexibility to meet the care needs and the clinical circumstances of a specific patient | ||
| D) | Implementing policies that limit opioid access regardless of pain severity, quality, or effectiveness of nonopioid therapy |
Each of the 12 recommendations is followed by considerations for implementation. These implementation considerations offer practical insights meant to further inform clinician-patient decision-making for the respective recommendation and are not meant to be rigidly or inflexibly followed. In addition, these five guiding principles should broadly inform implementation across recommendations:
Acute, subacute, and chronic pain need to be appropriately and effectively treated independent of whether opioids are part of a treatment regimen.
Recommendations are voluntary and are intended to support, not supplant, individualized, person-centered care. Flexibility to meet the care needs and the clinical circumstances of a specific patient are paramount.
A multimodal and multidisciplinary approach to pain management attending to the physical health, behavioral health, long-term services and supports, and expected health outcomes and well-being of each person is critical.
Special attention should be given to avoid misapplying this updated clinical practice guideline beyond its intended use or implementing policies purportedly derived from it that might lead to unintended consequences for patients.
Clinicians, practices, health systems, and payers should vigilantly attend to health inequities, provide culturally and linguistically appropriate communication, including communication that is accessible to persons with disabilities, and ensure access to an appropriate, affordable, diversified, coordinated, and effective nonpharmacologic and pharmacologic pain management regimen for all persons.
| A) | Low back pain | ||
| B) | Headaches, including episodic migraine | ||
| C) | Pain related to minor surgeries typically associated with minimal tissue injury and only mild postoperative pain | ||
| D) | All of the above |
Opioids are not first-line therapy for many common acute pain conditions, including low back pain, neck pain, pain related to other musculoskeletal injuries (such as sprains, strains, tendonitis, bursitis), pain related to minor surgeries typically associated with minimal tissue injury and only mild postoperative pain (e.g., dental extraction), dental pain, kidney stone pain, and headaches, including episodic migraine.
| A) | Exercise therapy | ||
| B) | Mind-body practices | ||
| C) | Low-level laser therapy | ||
| D) | Cognitive-behavioral therapy |
Clinicians should recommend appropriate noninvasive, nonpharmacologic approaches to help manage chronic pain, such as exercise (e.g., aerobic, aquatic, resistance exercises) or exercise therapy (a prominent modality in physical therapy) for back pain, fibromyalgia, and hip or knee osteoarthritis; weight loss for knee osteoarthritis; manual therapies for hip osteoarthritis; psychological therapy, spinal manipulation, low-level laser therapy, massage, mindfulness-based stress reduction, yoga, acupuncture, and multidisciplinary rehabilitation for low back pain; mind-body practices (e.g., yoga, tai chi, qigong), massage, and acupuncture for neck pain; cognitive-behavioral therapy [CBT], myofascial release massage, mindfulness practices, tai chi, qigong, acupuncture, and multidisciplinary rehabilitation for fibromyalgia; and spinal manipulation for tension headache.
| A) | severe, acute pain. | ||
| B) | moderate, chronic pain. | ||
| C) | severe, continuous pain. | ||
| D) | acute pain at the end of life. |
ER/LA opioids should be reserved for severe, continuous pain. The FDA has noted that some ER/LA opioids should be considered only for patients who have received certain dosages of opioids of immediate-release opioids daily for at least 1 week.
| A) | Pregnancy | ||
| B) | Constipation | ||
| C) | Signs of impending overdose | ||
| D) | Desire to discontinue therapy |
For patients already receiving opioid therapy, clinicians should carefully weigh benefits and risks and exercise care when changing opioid dosage. If benefits outweigh risks of continued opioid therapy, clinicians should work closely with patients to optimize nonopioid therapies while continuing opioid therapy. If benefits do not outweigh risks of continued opioid therapy, clinicians should optimize other therapies and work closely with patients to gradually taper to lower dosages or, if warranted based on the individual circumstances of the patient, appropriately taper and discontinue opioids. Unless there are indications of a life-threatening issue, such as warning signs of impending overdose (e.g., confusion, sedation, slurred speech), opioid therapy should not be discontinued abruptly, and clinicians should not rapidly reduce opioid dosages from higher dosages (recommendation category: B, evidence type: 4).
| A) | within one to four weeks. | ||
| B) | after one month. | ||
| C) | every three months. | ||
| D) | annually. |
In addition to evaluating benefits and risks of opioids before starting opioid therapy (see Recommendation 2), clinicians should evaluate patients to assess benefits and risks of opioids within 1 to 4 weeks of starting long-term opioid therapy or of dosage escalation.
| A) | A patient older than 65 years of age | ||
| B) | A patient with obstructive sleep apnea | ||
| C) | A patient taking lower dosages of opioids | ||
| D) | A patient who is also taking an antidepressant |
Clinicians should offer naloxone when prescribing opioids, particularly to patients at increased risk for overdose, including patients with a history of overdose, patients with a history of substance use disorder, patients with sleep-disordered breathing, patients taking higher dosages of opioids (e.g., ≥50 MME/day), patients taking benzodiazepines with opioids (see Recommendation 11), and patients at risk for returning to a high dose to which they have lost tolerance (e.g., patients undergoing tapering or recently released from prison).
| A) | Clinicians should dismiss patients from care based on a toxicology test result. | ||
| B) | Clinicians should use unexpected toxicology test results to improve patient safety. | ||
| C) | When prescribing opioids for subacute or chronic pain, clinicians should consider toxicology testing to assess for prescribed medications as well as other prescribed and non-prescribed controlled substances. | ||
| D) | Clinicians who believe their patient might be diverting prescription opioids should consider toxicology testing to assist in determining whether prescription opioids can be discontinued without causing withdrawal. |
When prescribing opioids for subacute or chronic pain, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and non-prescribed controlled substances (recommendation category: B, evidence type: 4).
Toxicology testing should not be used in a punitive manner but should be used in the context of other clinical information to inform and improve patient care.
Clinicians should not dismiss patients from care based on a toxicology test result. Dismissal could have adverse consequences for patient safety, potentially including the patient obtaining opioids or other drugs from alternative sources and the clinician missing opportunities to facilitate treatment for substance use disorder.
Prior to starting opioids and periodically (at least annually) during opioid therapy, clinicians should consider the benefits and risks of toxicology testing to assess for prescribed opioids as well as other prescription and nonprescription controlled substances that increase risk for overdose when combined with opioids, including nonprescribed and illicit opioids and benzodiazepines.
| A) | unpredictable use of either medication. | ||
| B) | use with other substances including alcohol. | ||
| C) | use of higher-dosage opioids and higher-dosage benzodiazepines in combination. | ||
| D) | All of the above |
Risks of concurrent opioid and benzodiazepine use are likely to be greater with unpredictable use of either medication, with use of higher-dosage opioids and higher-dosage benzodiazepines in combination, or with use with other substances including alcohol (compared with long-term stable use of lower-dosage opioids and lower-dosage benzodiazepines without other substances).
| A) | Fentanyl | ||
| B) | Bupropion | ||
| C) | Naltrexone | ||
| D) | Buprenorphine or methadone |
For pregnant persons with opioid use disorder, medication for opioid use disorder (buprenorphine or methadone) is the recommended therapy and should be offered as early as possible in pregnancy to prevent harms to both the patient and the fetus.
| A) | Asking for specific medications | ||
| B) | Injecting medications meant for oral use | ||
| C) | Reluctance to decrease opioid dosing once stable | ||
| D) | Stockpiling medications during times when pain is less severe |
In addition to aberrant urine screens, there are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [24,25,26]:
Selling medications
Prescription forgery or alteration
Injecting medications meant for oral use
Obtaining medications from nonmedical sources
Resisting medication change despite worsening function or significant negative effects
Loss of control over alcohol use
Using illegal drugs or non-prescribed controlled substances
Recurrent episodes of:
Prescription loss or theft
Obtaining opioids from other providers in violation of a treatment agreement
Unsanctioned dose escalation
Running out of medication and requesting early refills
Behaviors with a lower level of evidence for their association with opioid misuse include [24,25,26]:
Aggressive demands for more drug
Asking for specific medications
Stockpiling medications during times when pain is less severe
Using pain medications to treat other symptoms
Reluctance to decrease opioid dosing once stable
In the earlier stages of treatment:
Increasing medication dosing without provider permission
Obtaining prescriptions from sources other than the pain provider
Sharing or borrowing similar medications from friends/family
| A) | Institutes of Medicine | ||
| B) | U.S. Drug Enforcement Administration | ||
| C) | Office of National Drug Control Policy | ||
| D) | U.S. Department of Health and Human Services |
The U.S. Drug Enforcement Administration (DEA) is responsible for formulating federal standards for the handling of controlled substances. In 2011, the DEA began requiring every state to implement electronic databases that track prescribing habits, referred to as PDMPs. Specific policies regarding controlled substances are administered at the state level [29].
| A) | Product-specific information | ||
| B) | Risk factors, signs, and symptoms of overdose | ||
| C) | Instructions for safe sharing of opioids with others | ||
| D) | Warning and rationale to avoid other central nervous system depressants |
When prescribing opioids, clinicians should provide patients with the following information [11]:
Product-specific information
Taking the opioid as prescribed
Importance of dosing regimen adherence, managing missed doses, and prescriber contact if pain is not controlled
Warning and rationale to never break or chew/crush tablets or cut or tear patches prior to use
Warning and rationale to avoid other central nervous system depressants, such as sedative-hypnotics, anxiolytics, alcohol, or illicit drugs
Warning not to abruptly halt or reduce the opioid without physician oversight of safe tapering when discontinuing
The potential of serious side effects or death
Risk factors, signs, and symptoms of overdose and opioid-induced respiratory depression, gastrointestinal obstruction, and allergic reactions
The risks of falls, using heavy machinery, and driving
Warning and rationale to never share an opioid analgesic
Rationale for secure opioid storage
Warning to protect opioids from theft
Instructions for disposal of unneeded opioids, based on product-specific disposal information
| A) | Patients are almost always advised of what to do with unused or expired medications. | ||
| B) | There are no universal recommendations for the proper disposal of unused opioids. | ||
| C) | According to the FDA, most medications should be flushed down the toilet instead of thrown in the trash. | ||
| D) | All of the above |
There are no universal recommendations for the proper disposal of unused opioids, and patients are rarely advised of what to do with unused or expired medications [31]. According to the FDA, most medications that are no longer necessary or have expired should be removed from their containers, mixed with undesirable substances (e.g., cat litter, used coffee grounds), and put into an impermeable, nondescript container (e.g., disposable container with a lid or a sealed bag) before throwing in the trash [32]. Any personal information should be obscured or destroyed. The FDA recommends that certain medications, including oxycodone/acetaminophen (Percocet), oxycodone (OxyContin tablets), and transdermal fentanyl (Duragesic Transdermal System), be flushed down the toilet instead of thrown in the trash [32,33]. The FDA provides a free toolkit of materials (e.g., social media images, fact sheets, posters) to raise awareness of the serious dangers of keeping unused opioid pain medicines in the home and with information about safe disposal of these medicines. The Remove the Risk Outreach toolkit is updated regularly and can be found at https://www.fda.gov/drugs/ensuring-safe-use-medicine/safe-opioid-disposal-remove-risk-outreach-toolkit [33]. Patients should be advised to flush prescription drugs down the toilet only if the label or accompanying patient information specifically instructs doing so.
| A) | The use of interpreters | ||
| B) | Frequent career changes | ||
| C) | Perspective taking and role playing | ||
| D) | Increased opioid prescribing for racial/ethnic minority patients |
It is important to note that disparities in pain management are not typically intentional. Instead, they are the result of a myriad of issues, including healthcare system, socioeconomic, and cultural factors. However, prescriber and dispenser unconscious bias can contribute to the undertreatment of pain in certain groups. Promoting positive emotions such as empathy and compassion can help reduce implicit biases. This can involve strategies like perspective taking and role playing [47]. In a study examining analgesic prescription disparities, nurses were shown photos of White or Black American patients exhibiting pain and were asked to recommend how much pain medication was needed; a control group was not shown photos. Those who were shown images of patients in pain displayed no differences in recommended dosage along racial lines; however, those who did not see the images averaged higher recommended dosages for White patients compared with Black patients [48]. This suggests that professionals' level of empathy (enhanced by seeing the patient in pain) affected prescription recommendations.