NON-MALIGNANT AND NON-SURGICAL PAIN

KEY RECOMMENDATIONS (Based on 2016 CDC Guidelines):

  • Non-pharmacological (e.g. exercise, cognitive behavioral therapy) and non-opioid pharmacological therapies are preferred for managing chronic pain.
  • Opioids should be prescribed only after setting clear treatment goals focused on both improving function and decreasing pain. Risks of opioid use for chronic pain should be discussed explicitly.
  • Immediate-release opioids are strongly, if not exclusively, preferred over extended-release or long-acting opioids; methadone is not the preferred choice for a long-acting opioid.
  • Clinicians should initiate opioids at the lowest effective dose. When dosage must be escalated, doses should be limited to MMEs (morphine mg equivalents) of 50 MMEs (Ex. 50 mg of hydrocodone or 33 mg of oxycodone) daily in most circumstances, and no more than 90 MMEs daily without special justification.
  • Clinicians recommending tapering of chronic opioids, should do so thoughtfully, utilizing evidence-based tapering guidelines, providing patient education and support.
  • Opioid prescriptions for acute pain should be limited to 3 days in most circumstances.
  • Benefits and harms of opioid therapy should be reviewed when starting therapy or increasing dose and regularly thereafter.
  • Opioid use should be avoided in patients with sleep-disordered breathing or with renal or hepatic insufficiency, in those who are pregnant, and in elders (age, ≥65).
  • Clinicians should make naloxone available for patients at high risk of overdose, particularly those patients with opiate doses over 50 MME.
  • Data from state prescription monitoring programs should be reviewed at the initiation of opioid therapy and periodically thereafter.
  • Consider using urine drug testing at initiation of opioid therapy and periodically thereafter.
  • Concomitant benzodiazepine and alcohol use increases risk for overdose and should be avoided.
  • Clinicians should monitor patients for opioid-use disorder and refer as indicated to qualified addiction services (addiction behaviors or excessive use).
  • Concomitant use of cannabis is not recommended as evidence of safety has not been demonstrated.