Long-Term Opioid Therapy for Nonterminal Pain

Chronic pain, defined as persistent pain lasting longer than 12 weeks, affects approximately 20% of US adults and often results in mental and social burdens. In general, nonopioid therapies are preferred for chronic nonterminal pain, and opioid therapy should not be considered a first-line treatment modality. Health disparities in pain management affect vulnerable populations, including racially and ethnically marginalized groups and those with cognitive impairment. Clinicians first must acknowledge the existing health inequities and the stigma surrounding chronic pain and then need to provide culturally tailored pain management. Opioid use should be limited to circumstances wherein benefits outweigh risks, such as in cases of nonterminal pain refractory to multiple other interventions. Harms of opioid therapy include constipation, depression, hormonal dysregulation, opioid-induced hyperalgesia, and overdose. Given the high prevalence of behavioral health disorders in individuals with chronic pain, it is crucial to address mental health in conjunction with pain management. Before prescribing opioids, it is essential to review risk factors for opioid use disorder and respiratory depression and to set realistic goals for improving function. Ongoing monitoring should include assessments of functional progress, urine drug testing, and review of data from the state prescription drug monitoring program. Buprenorphine is an effective medication for chronic pain management and may be safer than full opioid agonists, especially in individuals at risk for opioid use disorder, opioid misuse, or overdose.