Pain Treatment Toolbox
Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred as first-line treatment for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The benefits of long-term opioid therapy for chronic pain – for example, from low back pain, headache, and fibromyalgia – are not well supported by the available evidence.
Fact Sheet :
When You Decide to Prescribe Opioids
1 Acute Pain Therapy
Long-term opioid use often begins with treatment of acute pain. So, when opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids for the shortest therapeutic duration. Three days or less will often be sufficient; more than seven days will rarely be needed.
2 Long-Term Therapy Considerations
Experts agreed that before opioid therapy is initiated for chronic pain outside of active cancer, palliative, and end-of-life care, prescribers should determine how effectiveness will be evaluated and should establish treatment goals with patients. Because the line between acute pain and initial chronic pain is not always clear, it might be difficult for prescribers to determine when they are initiating opioids for chronic pain rather than treating acute pain. Pain lasting longer than 3 months or past the time of normal tissue healing (which could be substantially shorter than 3 months, depending on the condition) is generally no longer considered acute.
Fact Sheets :
3 Opioid Dosing
Higher dosages of opioids are associated with higher risk of overdose and death, but higher dosages have not been shown to reduce pain over the long term. Extra precautions should be used when increasing to ≥ 50 morphine milligram equivalents (MME) per day and avoid or carefully justify increasing dosage ≥ 90 MME/day. There are a number of online MME calculators to help calculate the total dosage of opioids. Because of an increased risk of fatal overdose, prescribers should avoid the combination of prescription opioids and benzodiazepines when possible. State Prescription Drug Monitoring Programs (PDMPs) can inform clinicians about the types and dosages of controlled substances a patient has received from other prescribers, which can be used to help determine the most appropriate opioid dose for their patient.
Fact Sheets :
Assessing Patients on Opioids
Clinicians should work with patients to establish pain treatment goals and check for improvements in pain and function regularly. Prescribers should taper or reduce dosage and discontinue opioids if a patient experiences more harms than benefits on opioid therapy. Tapering plans should be individualized. Suggested taper plans include a 10% decrease from the original dose per week or month, monitoring for withdrawal symptoms (drug craving, anxiety, insomnia, abdominal pain, vomiting, diarrhea, and tremors) with psychosocial and specialty support. Consult an addiction medicine specialist (as appropriate) to help support taper management.
Fact Sheet :
Opioid Use Disorder & Overdose Risk
Opioid use disorder, also referred to as addiction or dependence, is a medical condition that characterizes the compulsive use of opioids despite negative health and social consequences of continued use.
It is vital for clinicians to screen for substance use disorders among patients who are taking opioids and other drugs. Symptoms of opioid use disorder include strong desire for opioids, inability to control or reduce use, continued use despite interference with major obligations or social functioning, use of larger amounts over time, development of tolerance, spending a great deal of time to obtain and use opioids, and withdrawal symptoms that occur after stopping or reducing use, such as negative mood, nausea or vomiting, muscle aches, diarrhea, fever, and insomnia.
Clinicians can initially screen their patients for substance use disorders by asking “How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Other validated screening tools can be found at NIDAMED Screening Tools for Adults and Adolescents.
Medication-Assisted Treatment (MAT)
Clinicians who identify a patient with an opioid use disorder should provide or refer patients for MAT. MAT is the use of pharmacological medications – such as buprenorphine, methadone, and naltrexone – in combination with counseling and behavioral therapies. Research indicates that a combination of medication and behavioral therapies can successfully treat opioid use disorder and help sustain recovery among some people struggling with addiction.
Pocket Guide :
Opioid overdose-related deaths can be prevented when naloxone is administered in a timely manner. As an opioid antagonist, naloxone displaces opioids from receptor sites in the brain and reverses respiratory depression that usually is the cause of overdose deaths. Naloxone does not have the potential for abuse.
Clinicians should consider prescribing naloxone to patients at high-risk for overdose: history of overdose, history of substance use disorder, higher opioid dosage (≥ 50 MME/day), concurrent benzodiazepine use. Prior to the FDA approval of two recent products, injectable naloxone was typically supplied as a kit with two syringes. These kits require training on how to administer naloxone using a syringe. The FDA has approved an intranasal naloxone product and a naloxone auto-injector. The intranasal spray is a pre-filled, needle-free device that requires no assembly. The auto-injector can deliver a dose of naloxone through clothing, if necessary, when placed on the outer thigh.
Information for Prescribers:
More Information on Opioids, Tools & Free CME/Trainings:
Interactive training tool using the principles of health literacy and a multimodal, team-based approach to promote the appropriate, safe, and effective use of opioids to manage chronic pain.
Office of Disease Prevention and Health Promotion, Office of the Assistant Secretary for Health, 2016.
National Institute of Drug Abuse, 2016
U.S. Department of Health and Human Services, 2016
Association of State & Territorial Health Officials
Federation of State Medical Boards
National Safety Council