Fine added that sometimes patient self reports are unreliable, so the guideline recommends that pill counts, urine drug screening, family member or caregiver interviews and prescription monitoring data be used to check for possible abuse. "Although strong evidence is lacking on the best methods for managing high-risk patients, potential risks can be minimized by more frequent and intense monitoring compared to lower risk patients," he said.
Other recommendations in the APS/AAPM clinical practice guideline include:
Methadone: Use of methadone for pain management has increased dramatically but few trials have evaluated its benefits and harms for treatment of chronic non-cancer pain. Methadone, therefore, should be started at low doses and titrated slowly. Because of its long half-life and variable pharmacokinetics, the panel recommends methadone not be used to treat breakthrough pain or as an as-needed medication.
Abusers: Chronic opioid therapy must be discontinued in patients known to be diverting their medication or in those engaging in serious aberrant behaviors.
Breakthrough Pain: As-needed opioids can be prescribed based on initial and ongoing analysis of therapeutic benefit versus risk.
High Doses: Patients who need high doses of opioids (200 mg daily of morphine or equivalent) should be evaluated for adverse events on an ongoing basis. Clinicians should consider rotating pain medications when patients experience intolerable side effects or inadequate benefit despite appropriate dose increases.
Driving and Work Safety: Patients should be educated about the greater risk for impairment when starting chronic opioid therapy and counseled not to drive or engage in potentially dangerous work if impaired.
Pregnancy: Clinicians should counsel women about risks in pregnancy and encourage minimal or no use of chronic opioid therapy unless potential benefits outweigh risks.
The guideline on opioid therapy for chronic non-cancer pain is the sixth evidenced-based, pain management clinical practice guideline published by APS. Others have covered sickle-cell disease, arthritis, cancer, fibromyalgia, and low back pain.
"This is a milestone collaboration in which two leading organizations representing pain management have developed the first comprehensive, evidence-based clinical practice guideline to assist clinicians in managing chronic opioid therapy," said APS President Charles Inturrisi, PhD. "We are grateful to the American Academy of Pain Medicine for joining forces with APS in developing this long-awaited publication."