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1-40-Opioid Guidelines 2006.Indd Pain Physician. 2006;9:1-40, ISSN 1533-3159 Opioid Guidelines Opioid Guidelines in the Management of Chronic Non-Cancer Pain Andrea M. Trescot, MD, Mark V. Boswell, MD, Sairam L. Atluri, MD, Hans C. Hansen, MD, Timothy R. Deer, MD, Salahadin Abdi, MD, Joseph F. Jasper, MD, Vijay Singh, MD, Arthur E. Jordan, MD, Benjamin W. Johnson, MD, Roger S. Cicala, MD, Elmer E. Dunbar, MD, Standiford Helm II, MD, Kenneth G. Varley, MD, P.K. Suchdev, MD, John R. Swicegood, MD, Aaron K. Calodney, MD, Bentley A. Ogoke, MD, W. Stephen Minore, MD, and Laxmaiah Manchikanti, MD Background: Opioid abuse has in- lation of the essentials of guidelines, a series analysis of the literature, the authors uti- creased at an alarming rate. However, avail- of potential evidence linkages representing lized two systematic reviews, two narrative re- able evidence suggests a wide variance in conclusions, followed by statements regard- views, 32 studies included in prior systematic the use of opioids, as documented by differ- ing relationships between clinical interven- reviews, and 10 additional studies in the syn- ent medical specialties, medical boards, ad- tions and outcomes. thesis of evidence. The evidence was limited. vocacy groups, and the Drug Enforcement Methods: Consistent with the Agency Conclusion: These guidelines evaluat- Administration (DEA). for Healthcare Research and Quality (AHRQ) ed the evidence for the use of opioids in the Objectives: The objective of these opi- hierarchical and comprehensive standards, management of chronic non-cancer pain and oid guidelines by the American Society of In- the elements of the guideline preparation recommendations for management. These terventional Pain Physicians (ASIPP) is to pro- process included literature searches, litera- guidelines are based on the best available vide guidance for the use of opioids for the ture synthesis, systematic review, consen- scientifi c evidence and do not constitute in- treatment of chronic non-cancer pain, to bring sus evaluation, open forum presentations, fl exible treatment recommendations. Be- consistency in opioid philosophy among the formal endorsement by the Board of Direc- cause of the changing body of evidence, this many diverse groups involved, to improve the tors of the American Society of Intervention- document is not intended to be a “standard treatment of chronic non-cancer pain, and to al Pain Physicians (ASIPP), and blinded peer of care.” reduce the incidence of drug diversion. review. Evidence was designated based on Key Words: Chronic pain, persistent Design: A policy committee evaluated a scientifi c merit as Level I (conclusive), Level pain, controlled substances, substance systematic review of the available literature II (strong), Level III (moderate), Level IV (lim- abuse, dependency, prescription account- regarding opioid use in managing chronic ited), or Level V (indeterminate). ability, opioids, prescription monitoring, di- non-cancer pain. This resulted in the formu- Results: After an extensive review and version, guidelines CONTENTS 2.0 CHRONIC PAIN 3.7 Drug Diversion 2.1 Defi nitions 3.8 Controlling Diversion and Abuse 1.0 INTRODUCTION 2.2 Prevalence 3.8.1 Drug Enforcement 1.1 Purpose 2.3 Chronicity Administration (DEA) 1.2 Rationale and Importance 2.4 Health and Economic Impact 3.8.2 State Laws and Regulations 1.3 Objectives and Benefi ts 3.8.3 Prescription Drug Monitoring 1.4 Population and Preferences 3.0 OPIOIDS IN CHRONIC PAIN Programs 1.5 Implementation and Review 3.1 General Considerations 1.6 Application 3.2 Response to Undertreatment 4.0 PHARMACOLOGICAL CONSIDERATIONS 1.7 Focus 3.3 Opioid Use in Chronic Pain 4.1 Opioid Pharmacology 1.8 Methodology 3.4 Non-Medical Use of Prescription 4.1.1 Opioid Receptors Drugs 4.1.2 Opioid Categories 3.4.1 Center on Addiction and 4.1.3 Opioid Metabolism From: American Society of Interventional Pain Phy- 4.2 Pharmacology of Specifi c Opioids sicians, Paducah, KY Substance Abuse (CASA) Address Correspondence: Findings 4.2.1 Morphine Laxmaiah Manchikanti, MD 3.4.2 Physician Survey Highlights 4.2.2 Codeine Chief Executive Offi cer, ASIPP 3.4.3 Pharmacist Survey Highlights 4.2.3 Dihydrocodeine 81 Lakeview Drive, Paducah, KY 42001 3.4.4 Substance Abuse and 4.2.4 Hydrocodone E-mail: [email protected] Mental Health Services 4.2.5 Oxycodone Disclaimer: There was no external funding in the Administration (SAMHSA) 4.2.6 Hydromorphone preparation of this manuscript. Survey 4.2.7 Methadone Confl ict of Interest: None 3.4.5 Drug Abuse Warning Network 4.2.8 Fentanyl Funding: Internal funding was provided by the (DAWN) Reports 4.2.9 Meperidine American Society of Interventional Pain Physicians 3.5 Substance Abuse in Chronic Pain 4.2.10 Pentazocine and was limited to travel and lodging expenses for 3.6 Economic Impact 4.2.11 Propoxyphene the authors. 4.2.12 Tramadol 2 Trescot et al • Opioid Guidelines 4.3 Adverse Effects 6.0 CLINICAL EFFECTIVENESS 8.0 PRINCIPLES OF OPIOID USAGE 4.4 Drug Interactions 6.1 Introduction 8.1 Introduction 4.5 Drug Conversions 6.2 Systematic Reviews 8.2 Basic Philosophy 4.6 Opioid Therapy and Side Effects 6.3 Other Controlled Trials 8.3 Evaluation 4.6.1 Long-term opioid therapy 6.4 Infl uence of Psychopathology on 8.3.1 History 4.6.2 Opioid Induced Immunologic Opioid Effectiveness 8.3.2 Effect on Functional Status Effects 6.5 Summary of Evidence 8.3.3 Drug History 4.6.3 Opioid Induced Hormonal 8.4 Physical Examination 7.0 ADHERENCE MONITORING Changes 8.5 Laboratory Studies 7.1 Introduction 4.6.4 Opioid Induced Hyperalgesia 8.6 Psychological Evaluation 7.2 Screening for Opioid Abuse 4.6.5 Psychomotor Performance In 8.7 Medical Decision Making and 7.3 Urine Drug Testing Opioid Therapy Treatment Plan 7.4 Periodic Review and Monitoring 4.6.6 Breakthrough Pain 8.8 Consultation Management 7.4.1 Periodic Review 8.9 Informed Consent and Controlled 7.4.2 Periodic Monitoring Substance Agreement 5.0 TERMINOLOGY OF ABUSE AND ADDICTION 7.4.3 Prescription Drug Monitoring 5.1 Introduction 9.0 DOCUMENTATION AND MEDICAL RECORDS 7.4.4 Periodic Education 5.2 History 7.4.5 Pill Counts 10.0 KEY POINTS dently or in conjunction with other mo- essary management. This management 1.0 INTRODUCTION dalities of treatments. Multidisciplinary may include, or be independent of, inter- or comprehensive pain management dif- ventional techniques. 1.1 Purpose fers among specialties and may elicit con- Guidelines for the use of opioids in fusion. An interventionalist perceives 1.5 Implementation and Review the treatment of chronic non-cancer pain comprehensive treatment programs as The dates for implementation and are statements developed by the Ameri- programs with interventional techniques review were established: can Society of Interventional Pain Physi- as the primary treatment modality, with ♦ Effective date – February 1, 2006 cians (ASIPP) to improve quality and ap- physical therapy, medical therapy, and ♦ Scheduled review − July 1, 2007 ♦ propriateness of care, improve patient ac- psychological management as supple- Expiration date – January 31, 2008 cess, improve patient quality of life, im- mentary. prove efficiency and effectiveness, min- 1.6 Application imize abuse and diversion, and achieve 1.3 Objectives and Benefi ts These guidelines are primarily in- cost containment by improving the cost- The objectives of these guidelines are tended for use by interventional pain phy- benefit ratio. to bring consistency in opioid prescrib- sicians. Others managing chronic pain ing to the many diverse groups involved; patients with opioids may also find these 1.2 Rationale and Importance to provide analysis of evidence to treat a guidelines useful. Available evidence documents a wide chronic pain patient with opioids, thus, These guidelines do not constitute degree of variance in the prescribing pat- maintaining reasonable patient access inflexible treatment recommendations. It terns of physicians in regard to opioids while reducing the risk of drug diversion; is expected that a provider will establish a for chronic pain, as suggested by differ- to provide practical prescribing guidelines plan of care on a case-by-case basis, taking ent specialties, medical boards, advocacy for physicians to reduce the risk of legal into account an individual patient’s medi- groups, and the Drug Enforcement Ad- and regulatory sanctions; and to empha- cal condition, personal needs, and prefer- ministration (DEA). size the need for systematic evaluation ences, as well as the physician’s experience. Opioids are commonly used in man- and ongoing care of patients with chronic Based on an individual patient’s needs, aging chronic non-cancer pain, even or persistent pain. treatment different from that outlined though this practice is controversial (1- The perceived benefits of these here could be warranted. These guidelines 3). However, documented abuse of opi- guidelines include: do not represent a “standard of care.” oids is increasing at an alarming rate (4- ♦ Improved patient compliance 11). While speaking at ASIPP’s 2004 an- ♦ Improved patient care with appropriate 1.7 Focus nual meeting in Washington, DC, Patricia medical management These guidelines focus on the effec- Good of the DEA’s Drug Diversion Con- ♦ Reduced misconceptions among tive management of chronic non-cancer trol division, stated that the United States, providers and patients about opioids pain as well as the multiple issues related to ♦ with 4.6% of the world’s population, uses Improved ability to manage patient opioid administration. It is recognized that expectations management of chronic non-cancer pain 80% of the world’s opioids. ♦ Reduced abuse and diversion Interventional pain management, as ♦ Improved cooperation among patients, takes place in a wide context of healthcare defined by the National Uniform Claims providers, and regulatory agencies. involving multiple specialists and multiple Committee (NUCC), is the discipline of techniques.
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