Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

Chou, Roger; Fanciullo, Gilbert J.; Fine, Perry G.; Adler, Jeremy A.; Ballantyne, Jane C.; Davies, Pamela; Donovan, Marilee I.; Fishbain, David A.; Foley, Kathy M.; Fudin, Jeffrey; Gilson, Aaron M.; Kelter, Alexander; Mauskop, Alexander; O'Connor, Patrick G.; Passik, Steven D.; Pasternak, Gavril W.; Portenoy, Russell K.; Rich, Ben A.; Roberts, Richard G.; Todd, Knox H.; Miaskowski, Christine

doi:10.1016/j.jpain.2008.10.008

Cited by 2,192Opioid Use Disorder TreatmentPain Management and Opioid UseAnesthesia and Pain Management

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

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Chou, Roger, Fanciullo, Gilbert J., Fine, Perry G., Adler, Jeremy A., Ballantyne, Jane C., Davies, Pamela, Donovan, Marilee I., Fishbain, David A. +13 more·2009·The Journal of Pain

DOI 10.1016/j.jpain.2008.10.008PMC PMC4043401

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Abstract

UNLABELLED: Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. PERSPECTIVE: Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

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There is no evidence for the effectiveness of opioids in long-term use.
“When evaluating potential use of opioids, it is important to bear in mind that there is no evidence for their effectiveness in long-term use and that there are risks of potentially serious adverse effects including drowsiness, constipation, endocrine, respiratory depression and even death.”
From Identification and Management of Chronic Pain in Primary Care: a Review (2016) · cites this paper as [35]
Once patients have been started on opioids, it can be challenging to discontinue their use because of the risk of clinical dependence and addiction.
“Compounding both these factors is the risk of clinical dependence and addiction, meaning that once patients have been started on opioids, it can be challenging to discontinue their use [35].”
From Identification and Management of Chronic Pain in Primary Care: a Review (2016) · cites this paper as [35]
Opioids carry risks of potentially serious adverse effects including drowsiness, constipation, endocrine, respiratory depression and even death.
“When evaluating potential use of opioids, it is important to bear in mind that there is no evidence for their effectiveness in long-term use and that there are risks of potentially serious adverse effects including drowsiness, constipation, endocrine, respiratory depression and even death.”
From Identification and Management of Chronic Pain in Primary Care: a Review (2016) · cites this paper as [35]
Prescribing above 120-mg morphine equivalent dose per day requires specialist supervision.
“It is important to note that prescribing above 120-mg morphine equivalent dose per day requires specialist supervision [35].”
From Identification and Management of Chronic Pain in Primary Care: a Review (2016) · cites this paper as [35]

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Research works printed but not linked: 4

[19]Chou R Huffman L The use of opioids for chronic non-cancer pain: evidence review American Pain Society 2009
[64]Kalso E Edwards J Moore R McQuay H Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 2004 112 372 380 15561393
[94]Pain & Policy Studies Group Achieving balance in federal and state pain policy: A guide to evaluation 2007 University of Wisconsin - Paul P. Carbone Comprehensive Cancer Center Madison Fourth edition
[95]Pain & Policy Studies Group Achieving balance in state pain policy: A progress report card 2007 University of Wisconsin-Paul P. Carbone Comprehensive Cancer Center Third edition

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Authors: Chou, R., Fanciullo, G. J., Fine, P. G., Adler, J. A., Ballantyne, J. C., Davies, P., Donovan, M. I., Fishbain, D. A., Foley, K. M., Fudin, J., Gilson, A. M., Kelter, A., Mauskop, A., O'Connor, P. G., Passik, S. D., Pasternak, G. W., Portenoy, R. K., Rich, B. A., Roberts, R. G., Todd, K. H., & Miaskowski, C.
Affiliations: Oregon Health & Science University (US)
Dartmouth College (US)
University of Utah (US)
Harvard University (US)
Seattle Cancer Care Alliance (US)
Kaiser Permanente (US)
University of Miami (US)
Memorial Sloan Kettering Cancer Center (US)
Albany College of Pharmacy and Health Sciences (US)
University of Wisconsin–Madison (US)
California Health and Human Services Agency (US)
New York Headache Center (US)
Mount Sinai Beth Israel (US)
University of California, Davis (US)
University of California, San Francisco (US)
Corresponding author: Chou, Roger
ORCID: Chou, Roger
Ballantyne, Jane C.
Davies, Pamela
Fishbain, David A.
Fudin, Jeffrey
Gilson, Aaron M.
Mauskop, Alexander
Pasternak, Gavril W.
Portenoy, Russell K.
Todd, Knox H.
Miaskowski, Christine
Venue: The Journal of Pain
Publisher: Elsevier BV
Published: 2009-02
Volume: 10
Issue: 2
Pages: 113-130.e22
ISSN: 1526-5900 (ISSN-L)
DOI: 10.1016/j.jpain.2008.10.008
PMC: PMC4043401
OpenAlex: W2024012275
Cited by: 2,192
References: 138
Citations by year: 2026: 21 · 2025: 40 · 2024: 45 · 2023: 72 · 2022: 73 · 2021: 78 · 2020: 157 · 2019: 117 · 2018: 158 · 2017: 176 · 2016: 182 · 2015: 189 · 2014: 173 · 2013: 159 · 2012: 174
FWCI: 183.34
Type: journal article
Language: en
Open access: hybrid
doi.org
Licence: cc-by-nc-nd
www.elsevier.com/tdm/userlicense/1.0/ (tdm)
www.elsevier.com/legal/tdmrep-license (tdm)
www.elsevier.com/open-access/userlicense/1.0/ (vor, 5335 d)
Locations: Journal of Pain (publishedVersion, cc-by-nc-nd)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: American Pain Society
National Institute on Drug Abuse (R01DA002615, K05DA000220, R01DA007242, R01DA006241)
Topics: Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Opioid Use Disorder Treatment
Health Sciences › Medicine › Anesthesiology and Pain Medicine › Pain Management and Opioid Use
Health Sciences › Medicine › Surgery › Anesthesia and Pain Management
Keywords: long-term opioid therapy, chronic non-cancer pain, opioid prescribing, opioid abuse potential, opioid use disorder, opioid diversion, patient selection, risk stratification, informed consent, methadone, dose escalation, opioid rotation, breakthrough pain, patient-centered medical home, opioid policy
MeSH terms: Analgesics, Opioid, Chronic Disease, Dose-Response Relationship, Drug, Female, Humans, Male, Opioid-Related Disorders, Pain, Pain Measurement, Pregnancy, Treatment Outcome, Drug Monitoring

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