A thorough pain assessment is vital to the initial evaluation of a patient and must be performed to guide treatment decisions. [1, 2, 3, 4, 5]
Dosing may be done incrementally and titrated to analgesic effect. Particularly in those without prior analgesic use, effects are variable and overdosing in these patients can result in adverse events.
Individualize doses based on risk for adverse outcomes, prior effective doses, comorbidities, concomitant medications, and response to therapy.
Immediate-release opioids are recommended for breakthrough pain.
When possible, use the same class of opioid analgesic for long-acting (ie, 24-hour scheduled doses) and short-acting (ie, PRN doses for breakthrough pain) pain relief.
Dosing charts are guidelines only.
Most data are reported for opioid-tolerant patients so must be used with caution.
The Centers for Disease Control and Prevention (CDC) issued recommendations for prescribing opioids for chronic pain. The recommendations included the following: [6, 7]
Nonpharmacologic therapy and nonopioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacologic therapy, as appropriate.
Before starting opioid therapy for chronic pain, clinicians should establish treatment goals with all patients, including realistic goals for pain and function, and should consider how opioid therapy will be discontinued if benefits do not outweigh risks. Clinicians should continue opioid therapy only if there is clinically meaningful improvement in pain and function that outweighs risks to patient safety.
Before starting and periodically during opioid therapy, clinicians should discuss with patients known risks and realistic benefits of opioid therapy and patient and clinician responsibilities for managing therapy.
When starting opioid therapy for chronic pain, clinicians should prescribe immediate-release opioids instead of extended-release/long-acting (ER/LA) opioids.
When opioids are started, clinicians should prescribe the lowest effective dosage. Clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing the dosage to ≥50 morphine milligram equivalents (MME)/day, and should avoid increasing the dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.
Long-term opioid use often begins with treatment of acute pain. When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than 7 days will rarely be needed.
Clinicians should evaluate benefits and harms with patients within 1-4 wk of starting opioid therapy for chronic pain or of dose escalation. Clinicians should evaluate benefits and harms of continued therapy with patients every 3 mo or more frequently. If benefits do not outweigh harms of continued opioid therapy, clinicians should optimize other therapies and work with patients to taper opioids to lower dosages or to taper and discontinue opioids.
Before starting and periodically during continuation of opioid therapy, clinicians should evaluate risk factors for opioid-related harms. Clinicians should incorporate, into the management plan, strategies to mitigate risk, including considering offering naloxone when factors that increase risk for opioid overdose, such as history of overdose, history of substance use disorder, higher opioid dosages (≥50 MME/day), or concurrent benzodiazepine use, are present.
Clinicians should review the patient’s history of controlled substance prescriptions using state prescription drug monitoring program (PDMP) data to determine whether the patient is receiving opioid dosages or dangerous combinations that put him or her at high risk for overdose. Clinicians should review PDMP data when starting opioid therapy for chronic pain and periodically during opioid therapy for chronic pain, ranging from every prescription to every 3 mo.
When prescribing opioids for chronic pain, clinicians should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually to assess for prescribed medications as well as other controlled prescription drugs and illicit drugs.
Clinicians should avoid prescribing opioid pain medication and benzodiazepines concurrently whenever possible.
Clinicians should offer or arrange evidence-based treatment (usually medication-assisted treatment with buprenorphine or methadone in combination with behavioral therapies) for patients with opioid use disorder.
Conversion from oral or transdermal to parenteral route results in more rapid analgesic effects. In cancer patients this is successful 75-95% of the time.
1. US Department of Health and Human Services, Centers for Disease Control and Prevention . Health, United States, 2011 with Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center for Health Statistics; 2011.
2. Dalacorte RR, Rigo JC, Dalacorte A. Pain management in the elderly at the end of life. N Am J Med Sci. 2011;3(8):348–354.[PMC free article][PubMed]
3. World Health Organization . Cancer pain relief. Geneva: World Health Organization; 1996. [Accessed December 5, 2012]. Available from: http://whqlibdoc.who.int/publications/9241544821.pdf.
4. American Society of Anesthesiologists Task Force on Acute Pain Management Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology. 2004;100(6):1573–1581.[PubMed]
5. AGS Panel on Persistent Pain in Older Persons The management of persistent pain in older persons. J Am Geriatr Soc. 2002;50(Suppl 6):S205–S224.[PubMed]
6. Simon LS, Lipman AG, Caudill-Slosberg M, et al., editors. Guideline for the Management of Pain in Osteoarthritis, Rheumatoid Arthritis and Juvenile Chronic Arthritis. 2nd ed. Chicago, IL: American Pain Society; 2002. Management of pain in osteoarthritis and rheumatoid arthritis; pp. 43–77.
7. Chou R, Fanciullo GJ, Fine PG, et al. American Pain Society-American Academy of Pain Medicine Opioids Guidelines Panel Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–130.[PMC free article][PubMed]
8. Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A, National Opioid Use Guideline Group Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 1: general population. Can Fam Physician. 2011;57(11):1257–1266. e407–e418.[PMC free article][PubMed]
9. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 – guidance. Pain Physician. 2012;15(suppl 3):S67–S116.[PubMed]
10. Cepeda MS, Farrar JT, Baumgarten M, Boston R, Carr DB, Strom BL. Side effects of opioids during short-term administration: effect of age, gender, and race. Clin Pharmacol Ther. 2003;74(2):102–112.[PubMed]
11. Lötsch J, von Hentig N, Freynhagen R, et al. Cross-sectional analysis of the influence of currently known pharmacogenetic modulators on opioid therapy in outpatient pain centers. Pharmacogenet Genomics. 2009;19(6):429–436.[PubMed]
12. Riley J, Ross JR, Rutter D, et al. No pain relief from morphine? Individual variation in sensitivity to morphine and the need to switch to an alternative opioid in cancer patients. Support Care Cancer. 2006;14(1):56–64.[PubMed]
13. Pergolizzi J, Böger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone) Pain Pract. 2008;8(4):287–313.[PubMed]
14. Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage. 2009;38(3):418–425.[PMC free article][PubMed]
15. Kahan M, Wilson L, Mailis-Gagnon A, Srivastava A, National Opioid Use Guideline Group Canadian guideline for safe and effective use of opioids for chronic noncancer pain: clinical summary for family physicians. Part 2: special populations. Can Fam Physician. 2011;57(11):1269–1276. e419–e428.[PMC free article][PubMed]
16. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I-evidence assessment. Pain Physician. 2012;15(suppl 3):S1–S65.[PubMed]
17. Webster LR, Fine PG. Review and critique of opioid rotation practices and associated risks of toxicity. Pain Med. 2012;13(4):562–570.[PubMed]
18. Quigley C. Opioid switching to improve pain relief and drug tolerability. Cochrane Database Syst Rev. 2004;3:CD004847.[PubMed]
19. Vissers KC, Besse K, Hans G, Devulder J, Morlion B. Opioid rotation in the management of chronic pain: where is the evidence? Pain Pract. 2010;10(2):85–93.[PubMed]
20. Droney J, Riley J. Recent advances in the use of opioids for cancer pain. J Pain Res. 2009;2:135–155.[PMC free article][PubMed]
21. Gear RW, Miaskowski C, Gordon NC, Paul SM, Heller PH, Levine JD. Kappa-opioids produce significantly greater analgesia in women than in men. Nat Med. 1996;2(11):1248–1250.[PubMed]
22. Viganó A, Bruera E, Suarez-Almazor ME. Age, pain intensity, and opioid dose in patients with advanced cancer. Cancer. 1998;83(6):1244–1250.[PubMed]
23. Smith H, Bruckenthal P. Implications of opioid analgesia for medically complicated patients. Drugs Aging. 2010;27(5):417–433.[PubMed]
24. Smith HS. Opioid metabolism. Mayo Clin Proc. 2009;84(7):613–624.[PMC free article][PubMed]
25. Benítez-Rosario MA, Salinas-Martín A, Aguirre-Jaime A, Pérez-Méndez L, Feria M. Morphine-methadone opioid rotation in cancer patients: analysis of dose ratio predicting factors. J Pain Symptom Manage. 2009;37(6):1061–1068.[PubMed]
26. Gagnon B, Bielech M, Watanabe S, Walker P, Hanson J, Bruera E. The use of intermittent subcutaneous injections of oxycodone for opioid rotation in patients with cancer pain. Support Care Cancer. 1999;7(4):265–270.[PubMed]
27. Hale ME, Ahdieh H, Ma T, Rauck R, Oxymorphone ER, Study Group 1 Efficacy and safety of OPANA ER (oxymorphone extended release) for relief of moderate to severe chronic low back pain in opioid-experienced patients: a 12-week, randomized, double-blind, placebo-controlled study. J Pain. 2007;8(2):175–184.[PubMed]
28. Mercadante S, Casuccio A, Fulfaro F, et al. Switching from morphine to methadone to improve analgesia and tolerability in cancer patients: a prospective study. J Clin Oncol. 2001;19(11):2898–2904.[PubMed]
29. Morita T, Takigawa C, Onishi H, et al. Japan Pain, Rehabilitation, Palliative Medicine, and Psycho-Oncology (PRPP) Study Group Opioid rotation from morphine to fentanyl in delirious cancer patients: an open-label trial. J Pain Symptom Manage. 2005;30(1):96–103.[PubMed]
30. Narabayashi M, Saijo Y, Takenoshita S, et al. Opioid rotation from oral morphine to oral oxycodone in cancer patients with intolerable adverse effects: an open-label trial. Jpn J Clin Oncol. 2008;38(4):296–304.[PubMed]
31. de Stoutz ND, Bruera E, Suarez-Almazor M. Opioid rotation for toxicity reduction in terminal cancer patients. J Pain Symptom Manage. 1995;10(5):378–384.[PubMed]
32. Bruera E, Sloan P, Mount B, Scott J, Suarez-Almazor M. A randomized, double-blind, double-dummy, crossover trial comparing the safety and efficacy of oral sustained-release hydromorphone with immediate-release hydromorphone in patients with cancer pain. Canadian Palliative Care Clinical Trials Group. J Clin Oncol. 1996;14(5):1713–1717.[PubMed]
33. Thomsen AB, Becker N, Eriksen J. Opioid rotation in chronic non-malignant pain patients. A retrospective study. Acta Anaesthesiol Scand. 1999;43(9):918–923.[PubMed]
34. Kloke M, Rapp M, Bosse B, Kloke O. Toxicity and/or insufficient analgesia by opioid therapy: risk factors and the impact of changing the opioid. A retrospective analysis of 273 patients observed at a single center. Support Care Cancer. 2000;8(6):479–486.