Guideline sources The following summarized guidelines for the evaluation and management of opioids for pain are prepared by our editorial team based on guidelines from the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the Center for Disease Control (CDC 2022), the United States Department of Defense (DoD/VA 2022), the American Society of Clinical Oncology (ASCO 2022), the Global Alliance for Infection in Surgery (GAIS/WSES/AAST/SIAARTI 2022), the American Society of Pain and Neuroscience (ASPN 2021), the French Society of Anesthesia and Intensive Care (SFAR 2019), the American Gastroenterological Association (AGA 2019), the European Society of Medical Oncology (ESMO 2018), the Canadian Medical Association (CMA 2017), the American Society of Interventional Pain Physicians (ASIPP 2017), the American Society of Anesthesiologists (ASA/APS/ASRA 2016), and the Multinational Association of Supportive Care in Cancer (MASCC/ESMO 2016). 1 2 3 4 5 6 7 8 9 10 11 12 13 Calculator Calculator DIRE score for opioid prescriptio Prescription Opioid Misuse Inde https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 1/7 6/30/23, 1:23 AM Opioids for pain Pathway Guidelines 1. Diagnostic investigations Clinical history: assess the risk of suicide and self-directed violence when initiating, continuing, changing, or discontinuing long-term opioid therapy. A Show 3 more Review of prescriptions: review the patient's history of controlled substance prescriptions using state prescription drug monitoring program data when prescribing initial opioid therapy for acute, subacute, or chronic pain, and periodically during opioid therapy for chronic pain, to determine whether the patient is receiving opioid dosages or combinations putting the patient at high risk for overdose. B Screening for substance abuse: As per CDC 2022 guidelines, assess the benefits and risks of toxicology testing to assess for prescribed medications as well as other prescribed and nonprescribed controlled substances when initiating opioids for subacute or chronic pain. B As per ASIPP 2017 guidelines, screen for opioid abuse to identify opioid abusers before prescribing opioids for pain management. B Genetic testing: insufficient to recommend for or against obtaining genetic testing, such as for polymorphism of CYP2D6, to guide opioid dosing. 2. Medical management Indications for initiation: As per ASCO 2022 guidelines: Initiate opioids in patients with moderate-to-severe pain related to cancer or active cancer treatment, unless contraindicated. B Discuss goals regarding functional outcomes, shared expectations, and pain intensity, as well as any concerns about opioids before initiating opioid therapy. A As per CDC 2022 guidelines, consider initiating opioid therapy for acute, C subacute, or chronic pain if the benefits are anticipated to outweigh the risks to the patient and only after maximization of nonpharmacologic and nonopioid pharmacologic therapies. Discuss the realistic benefits and known risks of opioid therapy with patients before prescribing opioid therapy for pain management. B Cooperate with patients with subacute or chronic pain to establish treatment goals for pain and function, and develop a plan on how opioid therapy will be discontinued if the benefits do not outweigh the risks. B As per VA 2022 guidelines: Do not initiate opioid therapy for the management of chronic non-cancer pain. D https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 2/7 6/30/23, 1:23 AM Opioids for pain Pathway Do not initiate long-term opioid therapy, particularly for younger patients, as age is inversely associated with the risk of opioid use disorder and overdose. D As per ASPN 2021 guidelines, consider initiating opioids in patients with moderate-to-severe cancer-related pain. B As per CMA 2017 guidelines: Consider initiating a trial of opioids in patients with chronic, persistent non-cancer pain despite optimized nonopioid therapy, without current or past substance use disorder, and without other active psychiatric disorders. C Consider stabilizing the psychiatric disorder before initiating a trial of opioids in patients with chronic, persistent non-cancer pain with an active psychiatric disorder. C Opioid therapy: As per ASCO 2022 guidelines, consider offering any of the opioids approved by the U.S. FDA or other regulatory agencies for pain treatment in patients eligible for opioid treatment. C Show 4 more As per CDC 2022 guidelines, prescribe immediate-release rather than ER or long-acting opioids when initiating opioid therapy for acute, subacute, or chronic pain. B Show 4 more As per VA 2022 guidelines, consider prescribing buprenorphine instead of full agonist opioids due to the lower risk of overdose and misuse in patients receiving daily opioids for the treatment of chronic pain. C Show 4 more As per ASPN 2021 guidelines: Individualize opioid agent selection taking into account the variance in pain presentations and coexisting medical comorbidities. B Consider offering methadone when other opioids are ineffective, or additional NMDA or serotonin receptor modulation is desired. C Decide on dosing initiation depending on opioid tolerance with low introductory doses in na ve patients. C Offer a conservative approach starting at 75-90% less than the calculated equianalgesic dose using 1:15 to 1:20 conversion factor in opioid-tolerant patients. B As per ASIPP 2017 guidelines, initiate opioid therapy with low-dose, short-acting drugs, with appropriate monitoring. B Show 6 more As per CMA 2017 guidelines, restrict the prescribed dose of opioids to < 90 mg/day morphine equivalents in patients with chronic non-cancer pain initiating long-term opioid therapy. A Show 4 more Non-opioid therapies: As per ASCO 2022 guidelines, consider continuing other analgesics, such as NSAIDs, after opioid initiation in patients already taking these analgesics, if they provide additional analgesia and are not contraindicated. C As per CDC 2022 guidelines: https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 3/7 6/30/23, 1:23 AM Opioids for pain Pathway Maximize the use of nonpharmacologic and nonopioid pharmacologic therapies as appropriate for the specific condition before initiating opioid therapy for acute, B subacute, or chronic pain. B Recognize that nonopioid therapies are at least as effective as opioids for many common types of acute pain, B meanwhile, nonopioid therapies are preferred for subacute and chronic pain. B Be particularly cautious when prescribing opioids and benzodiazepines concurrently. Discuss whether the benefits outweigh the risks of concurrent prescribing of opioids and other CNS depressants. B As per VA 2022 guidelines, do not use benzodiazepines concurrently with opioids for chronic pain. D As per CMA 2017 guidelines, optimize nonpharmacological and nonopioid pharmacological therapies, rather than initiating a trial of opioids, as first-line treatment in patients with chronic non-cancer pain. A Non-opioid therapies (CEG-CCP): Offer cannabinoid-based medicines as an adjunct treatment in patients taking moderate/high doses of opioids ( > 50 morphine equivalent) for the management of chronic pain and/or to increase opioid sparing. B Offer cannabinoid-based medicines as an adjunct treatment for chronic pain in patients taking any dose of opioids not reaching chronic pain goals, experiencing opioid-related adverse events, or displaying risk factors for opioid-related harm. B Antiemetic prophylaxis: insufficient evidence to recommend antiemetic prophylaxis for opioid- induced nausea and vomiting. I 3. Perioperative care Preoperative counseling: consider providing patients with preoperative opioid and pain management education to decrease the risk of prolonged opioid use for postoperative pain. C 4. Specific circumstances Patients with postoperative pain: As per WSES 2022 guidelines, administer a major opioid for the treatment of moderate-to- severe pain unresponsive to other medications, if regional anesthesia techniques are not indicated. B Show 4 more As per SFAR 2019 guidelines, administer strong opioids (morphine or oxycodone), ideally PO, for severe postoperative pain or if weaker analgesics are not powerful enough to relieve pain. A As per APS 2016 guidelines, prefer oral over IV route for opioid administration for postoperative analgesia, if possible. B https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 4/7 6/30/23, 1:23 AM Opioids for pain Pathway Show 2 more Patients with opioid use disorder: As per CDC 2022 guidelines, provide evidence-based treatment in patients with opioid use disorder. Do not offer detoxification alone without medications for opioid use disorder because of the increased risks of resuming drug use, overdose, and overdose death. A As per VA 2022 guidelines, insufficient evidence to recommend for or against any one of the following medications over the other for chronic pain in patients receiving medication for opioid use disorder: methadone, buprenorphine, or ER naltrexone injection. I Patients with substance use disorder: As per ASCO 2022 guidelines, collaborate with a palliative care, pain, and/or substance use disorder specialist to determine the optimal approach to pain management in patients with substance use disorder. A As per VA 2022 guidelines: Do not initiate long-term opioid therapy for chronic pain in patients with substance use disorder. D Consider offering interdisciplinary care addressing pain and/or behavioral health problems, including substance use disorders, in patients presenting with high-risk and/or aberrant behavior. C As per CMA 2017 guidelines: Do not initiate opioid therapy in patients with chronic non-cancer pain with an active substance use disorder. D Consider continuing nonopioid therapy rather than initiating a trial of opioids in patients with chronic, persistent non-cancer pain with a history of substance use disorder. C Patients with renal/hepatic impairment: Consider switching to methadone, if not contraindicated, in patients with renal impairment currently treated with an opioid. Titrate opioids primarily eliminated in the urine, such as fentanyl, oxycodone, and hydromorphone, and obtain frequent monitoring for risk or accumulation of the parent drug or active metabolites. Avoid using morphine, meperidine, codeine, and tramadol in these patients, unless there are no alternatives. B Obtain more frequent clinical observation and opioid dose adjustment in patients with renal or hepatic impairment receiving opioids. A Patients with opioid-induced constipation: As per AGA 2019 guidelines, offer laxatives as first-line therapy in patients with opioid-induced constipation. B Show 2 more As per ESMO 2018 guidelines, prescribe a concomitant laxative in all patients receiving opioid analgesics unless contraindicated by preexisting diarrhea. B Show 3 more https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 5/7 6/30/23, 1:23 AM Opioids for pain Pathway 5. Follow-up and surveillance Clinical monitoring: As per ASCO 2022 guidelines, offer education and strategies to prevent known opioid-related adverse effects, monitor for the development of these adverse effects, and manage these effects when they occur. A As per CDC 2022 guidelines, evaluate benefits and risks of opioid therapy within 1-4 weeks of initiation for subacute or chronic pain or of dosage escalation. Reevaluate benefits and risks of continued opioid therapy regularly. B Show 2 more As per VA 2022 guidelines, obtain reevaluation at 30 days or fewer after initiating opioid therapy, and frequent follow-up visits if opioids are to be continued. A Show 2 more As per ASIPP 2017 guidelines, obtain periodic assessments of pain relief and/or functional status improvement of 30% without adverse consequences. B Show 3 more Urine drug testing: consider obtaining urine drug testing in patients on long-term opioids. C Studies 2023 I-WOTCH In adults taking strong opioids to treat chronic nonmalignant pain, education and support were superior to usual care with respect to opioid discontinuation at 12 months. Harbinder K Sandhu et al. JAMA. 2023 May 23. References 1. Mansoor M Aman, Ammar Mahmoud, Timothy Deer et al. The American Society of Pain and Neuroscience ASPN Best Practices and Guidelines for the Interventional Management of Cancer- Associated Pain. J Pain Res. 2021 Jul 16;14 2139 2164. Open 2. Roger Chou, Debra B Gordon, Oscar A de Leon-Casasola et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016 Feb;17 2 131 57. Open 3. Deborah Dowell, Kathleen R Ragan, Christopher M Jones et al. CDC Clinical Practice Guideline for Prescribing Opioids for Pain United States, 2022. MMWR Recomm Rep. 2022 Nov 4;71 3 1 95. Open 4. Busse JW, Craigie S, Juurlink DN et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017 May 8;189 18 E659 E666. Open https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 6/7 6/30/23, 1:23 AM Opioids for pain Pathway 5. Department of Defense/Veterans Affairs. VA/DoD CLINICAL PRACTICE GUIDELINE FOR THE USE OF OPIOIDS IN THE MANAGEMENT OF CHRONIC PAIN. VA/DoD. 2022 May. Open 6. Judith A Paice, Kari Bohlke, Debra Barton et al. Use of Opioids for Adults With Pain From Cancer or Cancer Treatment: ASCO Guideline. J Clin Oncol. 2022 Dec 5;JCO2202198. Open 7. Fr d ric Aubrun, Karine Nouette-Gaulain, Dominique Fletcher et al. Revision of expert panel's guidelines on postoperative pain management. Anaesth Crit Care Pain Med. 2019 Aug;38 4 405 411. Open 8. F Roila, A Molassiotis, J Herrstedt et al. 2016 MASCC and ESMO guideline update for the prevention of chemotherapy- and radiotherapy-induced nausea and vomiting and of nausea and vomiting in advanced cancer patients. Ann Oncol. 2016 Sep;27(suppl 5):v119-v133. Open 9. Federico Coccolini, Francesco Corradi, Massimo Sartelli et al. Postoperative pain management in non- traumatic emergency general surgery: WSES GAIS SIAARTI AAST guidelines. World J Emerg Surg. 2022 Sep 21;17 1 50. Open 10. Laxmaiah Manchikanti, Adam M Kaye, Nebojsa Nick Knezevic et al. Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians ASIPP Guidelines. Pain Physician. 2017 Feb;20 2S S3 S92. Open 11. Larkin PJ, Cherny NI, La Carpia D et al. Diagnosis, assessment and management of constipation in advanced cancer: ESMO Clinical Practice Guidelines. Ann Oncol. 2018 Oct 1;29 Suppl 4):iv111-iv125. Open 12. Seth D Crockett, Katarina B Greer, Joel J Heidelbaugh et al. American Gastroenterological Association Institute Guideline on the Medical Management of Opioid-Induced Constipation. Gastroenterology. 2019 Jan;156 1 218 226. Open 13. Alan D Bell, Caroline MacCallum, Shari Margolese et al. Clinical Practice Guidelines for Cannabis and Cannabinoid-Based Medicines in the Management of Chronic Pain and Co-Occurring Conditions. Cannabis Cannabinoid Res. 2023 Mar 27. Open 14. Janet S Knisely, Martha J Wunsch, Karen L Cropsey et al. Prescription Opioid Misuse Index: a brief questionnaire to assess misuse. J Subst Abuse Treat. 2008 Dec;35 4 380 6. Open 15. Harbinder K Sandhu, Katie Booth, Andrea D Furlan et al. Reducing Opioid Use for Chronic Pain With a Group-Based Intervention: A Randomized Clinical Trial. JAMA. 2023 May 23;329 20 1745 1756. Open https://web.pathway.md/diseases/recUxMBxUcMo4WAVp 7/7