Chronic Opioid Therapy for Chronic Non-Cancer Pain: A Review and Comparison of Treatment Guidelines

Background: Long-term opioid use for chronic non-cancer pain has increased substantiallyin recent years despite the paucity of strong supporting scientific data and concerns regardingadverse effects and potential misuse.Study Design: Review and summary of practice guidelines available on PubMed andCochrane databases as well as on the Internet on chronic opioid therapy from June 2004 toJune 2013.Objective: To review expert-developed practice guidelines on chronic opioid therapy, publishedin different countries over the past decade in order to reveal similar principles of therapy andto provide useful information and references for future development of opioid guidelines toidentify adequately supported practice points and areas in need of further scientific evidence.Method: Seven guidelines were identified as pertaining specifically to the long-term use ofopioids for general chronic non-cancer pain from an initial search of the PubMed/Medlineand Cochrane databases using combinations of the search terms “opioid,” “chronic opioidtherapy,” “chronic pain,” “chronic non-cancer pain,” “chronic non-malignant pain,”“guidelines,” “practice guidelines,” and “clinical practice guidelines,” filtered to include onlyarticles on humans published in the English language over the past 10 years.Results: All guidelines espouse an individual approach to management, beginning with acomprehensive patient evaluation, with particular focus on eliciting factors that may indicatepotential drug misuse and abuse, and a trial of therapy to determine the course of treatment.Goals of treatment should be adequately discussed with and consented to by the patient.Opioids are generally not recommended as first-line therapy but, when used, clinicians shouldclosely monitor patients for loss of response, adverse effects or aberrant behavior, and revisethe treatment plan accordingly. Urine drug testing (UDT) may be used as a tool to monitor foraberrant behavior or drug misuse; opioid rotation may be considered when loss of response oradverse effects are a concern, at a starting dose lower than the calculated equianalgesic dose.Limitations: Information on some African nations, countries in the Middle-East, and PacificIslands is not available and therefore was not included in this review.Conclusion: There is a growing body of scientific evidence to support opioid use in chronicpain. Future work should focus on continuing to generate good-quality evidence on the longterm benefits of opioid therapy, as well as scientific data to guide drug choice and dosing forspecific conditions, populations, and situations.Key words: Chronic pain, opioid, non-cancer pain, guidelines, opioid rotation, painmanagement, opioid therapy