Opioids in the Management of Chronic Non-Cancer Pain: An Update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines

Background: Opioid abuse has continued to increase at an alarming rate since our last opioid guidelines were published in 2005. Available evidence suggests a continued wide variance in the use of opioids, as documented by different medical specialties, medical boards,advocacy groups, and the Drug Enforcement Administration.Objectives: The objectives of opioid guidelines by the American Society of InterventionalPain Physicians (ASIPP) are to provide guidance for the use of opioids for the treatment ofchronic non-cancer pain, to bring consistency in opioid philosophy among the many diversegroups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of abuse and drug diversion.Design: A broadly based policy committee of recognized experts in the field evaluated theavailable literature regarding opioid use in managing chronic non-cancer pain. This resultedin the formulation of the review and update of the guidelines published in 2006, a series ofpotential evidence linkages representing conclusions, followed by statements regarding therelationships between clinical interventions and outcomes.Methods: The elements of the guideline preparation process included literature searches,literature synthesis, consensus evaluation, open forum presentations, formal endorsement bythe Board of Directors of the American Society of Interventional Pain Physicians, and peer review. Based on the criteria of the U.S. Preventive Services Task Force, the quality of evidencewas designated as Level I, II, and III, with 3 subcategories in Level II, with Level I described asstrong and Level III as indeterminate. The recommendations were provided from 1A to 2C,varying from strong recommendation with high quality evidence to weak recommendationwith low-quality or very low-quality evidence.Results: After an extensive review and analysis of the literature, which included systematicreviews and all of the available literature, the evidence for the effectiveness of long-term opioids in reducing pain and improving functional status for 6 months or longer is variable. Theevidence for transdermal fentanyl and sustained-release morphine is Level II-2, whereas foroxycodone the level of evidence is II-3, and the evidence for hydrocodone and methadone isLevel III. There is also significant evidence of misuse and abuse of opioids.The recommendation is 2A – weak recommendation, high-quality evidence: with benefitsclosely balanced with risks and burdens; with evidence derived from RCTs without important limitations or overwhelming evidence from observational studies, with the implicationthat with a weak recommendation, best action may differ depending on circumstances orpatients’ or societal values.Conclusion: Opioids are commonly prescribed for chronic non-cancer pain and may be effective for short-term pain relief. However, long-term effectiveness of 6 months or longer isvariable with evidence ranging from moderate for transdermal fentanyl and sustained-release morphine with a Level II-2, to limited for oxycodone with a Level II-3, and indeterminate for hydrocodone and methadone with a Level III.These guidelines included the evaluation of the evidence for the use of opioids in the management of chronic non-cancerpain and the recommendations for that management. These guidelines are based on the best available evidence and do notconstitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a “standard of care.”Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drugabuse, dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion