Rational use of opioids for management of chronic nonterminal pain

Opioid prescribing for chronic nonterminal pain has increased in recent years, although evidence for its long-term effectiveness is weak and its potential for harm is significant. Nonmedical use of prescription opioids, diversion, and overdose deaths have also increased sharply, sparking concern about the safety of these medications. Physicians considering initiation or continuation of opioid therapy for a patient with chronic nonterminal pain should first use a structured approach that includes a biopsychosocial evaluation and a treatment plan that encourages patients to set and reach functional goals. There should be a comprehensive evaluation for the cause of pain, assessment for risk of opioid complications (including misuse and addiction), and a detailed treatment history, including a review of medical records and data from the state prescription monitoring program. Opioids should be prescribed on a trial basis, to be continued only if progress toward functional goals is demonstrated. Long-acting morphine is the preferred initial drug, although several alternatives are available. Ongoing monitoring for safety and effectiveness is essential, including regular review of functional progress or maintenance, urine drug testing, and surveillance of data from the state prescription monitoring program. Ineffective, unsafe, or diverted opioid therapy should be promptly tapered or stopped.