APS/AAPM Clinical Guidelines for Chronic Opioid Therapy in Patients with Noncancer Pain

The basis for the long-term use of opioids in the treatment of cancer pain has been fairly well established. Alternatively, a variety of controversies and differences of opinion have surrounded the use of opioid therapy when treating chronic noncancer pain. Issues range from the scientific basis for efficacy, safe and appropriate use, to health care provider’s fear of legislative reprimand for indiscriminate prescribing. Among the most significant of the controversies is the abuse and misuse of opioids as their use has increased substantially over the last 20 years, along with an increasing mortality rate from these aberrant behaviors.

Primary care clinicians and specialists alike have looked toward respected pain management experts and societies to guide them with evidence-based recommendations for the safe and appropriate use of opioids for the treatment of this significant patient population.

In response to this need, the American Pain Society (APS), in partnership with the American Academy of Pain Medicine (AAPM), commissioned a multidisciplinary panel that worked for over a year to develop evidence-based guidelines on chronic opioid therapy in adults with noncancer pain,1 which were published in 2009. These guidelines are based on a comprehensive and systematic review of published evidence on the subject. Most importantly, these guidelines are targeted towards both primary care and specialty settings, essentially “all clinicians who provide care for adults with chronic noncancer pain, including cancer survivors with chronic pain due to their cancer or its treatment.”

Below is a summary of the recommendations:

  1. Patient Selection and Risk Stratification
    1. A detailed history and physical
    2. Assessment of risk of likelihood of abuse, misuse, or addiction (Proper patient selection is critical and requires a comprehensive benefit-to-harm evaluation that weighs the potential positive effects of opioids on pain and function against potential risks. Thorough risk assessment and stratification is appropriate in every case.)
  2. Informed Consent and Opioid Management Plans
    1. Informed consent for opioid therapy should include items that any informed consent would normally contain:
      1. – Goals of treatment
      2. – Expectations
      3. – Risks and alternatives
    2. A written opioid management plan should be considered (for more information about patient-provider opioid agreements and a sample agreement, please visit www.PainEDU.org)
  3. Initiation and Titration of Chronic Opioid Therapy
    1. Initial treatment should always be considered individually determined, and as a trial of therapy – not a definitive course of treatment
  4. Use of Methadone
    1. The use of methadone is recommended to be utilized only by clinicians familiar with its use and risks
  5. Monitoring Patients
    1. Periodic reassessment is paramount, and includes documentation of:
      1. – Level of function
      2. – Progress towards predetermined goals
      3. – Presence of adverse events
      4. – Compliance (or lack of)
  6. High Risk Patients
    1. Should only be treated by clinicians that are able to implement more frequent and stringent monitoring approaches, such as a mental health or addiction specialists
  7. Dose Escalations, High-Dose Opioid Therapy, Opioid Rotation, and Indications for Discontinuation of Therapy
    1. – When repeated escalations are necessary, potential causes for the increased need, as well as risks and benefits should be considered
    2. – Increased vigilance such as more frequent follow-up visits should be considered in patients on high-dose opioid therapy
    3. – Opioid rotation should be considered for issues such as tolerance of adverse effects or unsatisfactory efficacy
    4. – Discontinuation of opioid therapy is recommended by tapering or weaning for patients who repeatedly engage in aberrant drug- related behaviors
  8. Opioid-Related Adverse Effects
    1. Common adverse effects need to be anticipated, and addressed appropriately
  9. Use of Psychotherapeutic Co-interventions
    1. These interventions such as cognitive behavioral therapy, along with other interdisciplinary therapy and other adjunctive non-opioid therapies should be routinely integrated into long-term opioid treatment
  10. Driving and Work Safety
    1. Counseling about transient or lasting cognitive impairment must be addressed with patients
  11. Identifying a Medical Home and When to Obtain Consultation
    1. A clinician needs to be identified as the person with primary responsibility for the patient’s overall medical care. This may or may not be the clinician prescribing the chronic opioid therapy, but should coordinate consultation and all communication among all disciplines involved in the patient’s care
    2. Consultation should be considered as in any other situation, when the clinician feels that the patient may benefit from other resources beyond their capability
  12. Breakthrough Pain
    1. prn opioids may be needed for patients on around-the-clock therapy, and should always be used based on a risk-benefit analysis
  13. Opioids in Pregnancy
    1. As in other situations, clinicians should counsel women of childbearing capacity about the risks and benefits of chronic opioid therapy during and after pregnancy. In most situations, their use during pregnancy should be discouraged or minimized unless benefits are determined to outweigh the risks
    2. In the event that chronic opioid therapy is utilized during pregnancy, the needs of the mother and the baby need to be appropriately anticipated
  14. Opioid Policies
    1. It is imperative that clinicians are aware of local policies surrounding the medical use of chronic opioids for noncancer pain patients, such as:
      1. – Federal laws
      2. – State laws
      3. – Regulatory guidelines
      4. – Policy statements

These guidelines may seem quite simplistic if taken individually. Their true significance lies in their use as a formulated plan to use opioids safely and appropriately in this very important population of patients. Very often, noncancer pain patients are denied the appropriate course of treatment, or quantity of therapeutic agent as the result of what has been a deficit in a strategic plan for approaching the long-term treatment of chronic pain with opioids. These guidelines can do much to improve the quality of care of these patients, and increase comfort levels of clinicians if utilized in their complete form. Coupled with good clinical judgment, these recommendations can provide clinicians with the framework for safer use of opioids and more efficacious care of patients with chronic noncancer pain, and also minimize the risk associated with their use.

Readers are encouraged to view the full publication at The Journal of Pain.

References

1. Chou R, Fanciullo GJ, Fine PG et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. The Journal of Pain: Official Journal Of The American Pain Society 2009; 10(2):113-130.