Chronic Pain Management with Opioids

Introduction to Chronic Pain Management

Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain management, with opioids considered only if expected benefits for both pain and function outweigh risks to the patient, as recommended by the American Medical Association and the Centers for Disease Control and Prevention 1, 2

Exercise therapy should be used to reduce pain and improve function in patients with chronic pain 1
Cognitive behavioral therapy (CBT) should be used to reduce pain and improve function in patients with chronic pain 1
Acetaminophen is recommended as a first-line treatment for musculoskeletal pain, according to the American College of Physicians 4, 3
NSAIDs are recommended as a first-line treatment for musculoskeletal pain, but with caution regarding GI, renal, and cardiovascular risks, as advised by the American Heart Association 4, 3

Opioids should not be considered first-line or routine therapy for chronic pain outside of active cancer, palliative, and end-of-life care due to small to moderate short-term benefits and uncertain long-term benefits, as stated by the Centers for Disease Control and Prevention 1, 5, 2
Opioids may be appropriate in specific circumstances, such as when other therapies have failed to provide adequate pain relief, in cases of serious illness with poor prognosis for return to function, or when contraindications to other therapies exist, as recommended by the American Medical Association 5, 1

Clear treatment goals should be established with patients, including realistic goals for pain and function, as advised by the American Academy of Pain Medicine 1, 2
Clinicians should discuss how opioid therapy will be discontinued if benefits do not outweigh risks, as recommended by the Centers for Disease Control and Prevention 2
Risk factors for opioid-related harms, such as history of substance use disorder, mental health comorbidities, sleep-disordered breathing, concurrent benzodiazepine use, and advanced age, should be considered before starting opioid therapy, as stated by the American Society of Addiction Medicine 3

Opioids should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy to provide greater benefits, as recommended by the American College of Physicians 1, 5
Opioid therapy should only be continued if there is clinically meaningful improvement in pain and function that outweighs risks, as advised by the Centers for Disease Control and Prevention 1, 2
Clinically meaningful improvement is defined as a 30% improvement in scores for both pain and function, as stated by the American Medical Association 1

Higher opioid dosages are associated with increased overdose risk, with dosages of 50-100 MME/day increasing risk by factors of 1.9 to 4.6 compared to 1-20 MME/day, and dosages ≥100 MME/day increasing risk by factors of 2.0 to 8.9, as reported by the Journal of the American Medical Association 3
The lowest effective dosage of opioids should be used when prescribing, as recommended by the American Academy of Pain Medicine 6

For patients with HIV and chronic pain, similar principles apply with careful consideration of opioid risks and benefits, as stated by the Infectious Diseases Society of America 4
In cases of neuropathic pain, a combination of morphine and gabapentin may be considered for potential additive effects, as recommended by the American Academy of Neurology 4
For osteoarthritis, tramadol may be considered for up to 3 months to decrease pain and improve function, as advised by the American College of Rheumatology 4