Opioid Therapy (OT) for Chronic Pain
Publication Date: February 1, 2017
Last Updated: March 14, 2022
Initiation and Continuation of Opioids
a) We recommend against initiation of long-term opioid therapy for chronic pain.
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b) We recommend alternatives to opioid therapy such as selfmanagement strategies and other non-pharmacological treatments.
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c) When pharmacologic therapies are used, we recommend nonopioids over opioids.
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If prescribing opioid therapy for patients with chronic pain, we recommend a short duration. (Strong for)
Note: Consideration of opioid therapy beyond 90 days requires reevaluation and discussion with patient of risks and benefits.
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For patients currently on long-term opioid therapy, we recommend ongoing risk mitigation strategies, assessment for opioid use disorder, and consideration for tapering when risks exceed benefits. (Strong for)
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a) We recommend against long-term opioid therapy for pain in patients with untreated substance use disorder.
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b) For patients currently on long-term opioid therapy with evidence of untreated substance use disorder, we recommend close monitoring, including engagement in substance use disorder treatment, and discontinuation of opioid therapy for pain with appropriate tapering.
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We recommend against the concurrent use of benzodiazepines and opioids. (Strong against)
Note: For patients currently on long-term opioid therapy and benzodiazepines, consider tapering one or both when risks exceed benefits and obtaining specialty consultation as appropriate.
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a) We recommend against long-term opioid therapy for patients less than 30 years of age secondary to higher risk of opioid use disorder and overdose.
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b) For patients less than 30 years of age currently on long-term opioid therapy, we recommend close monitoring and consideration for tapering when risks exceed benefits.
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We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include:
- Ongoing, random urine drug testing (including appropriate confirmatory testing)
- Checking state prescription drug monitoring programs
- Monitoring for overdose potential and suicidality
- Providing overdose education
- Prescribing of naloxone rescue and accompanying education
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Risk Mitigation
We recommend implementing risk mitigation strategies upon initiation of long-term opioid therapy, starting with an informed consent conversation covering the risks and benefits of opioid therapy as well as alternative therapies. The strategies and their frequency should be commensurate with risk factors and include:
- Ongoing, random urine drug testing (including appropriate confirmatory testing)
- Checking state prescription drug monitoring programs
- Monitoring for overdose potential and suicidality
- Providing overdose education
- Prescribing of naloxone rescue and accompanying education
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We recommend assessing suicide risk when considering initiating or continuing long-term opioid therapy and intervening when necessary. (Strong for)
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We recommend evaluating benefits of continued opioid therapy and risk for opioid-related adverse events at least every three months. (Strong for)
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Type, Dose, Follow-up, and Taper of Opioids
If prescribing opioids, we recommend prescribing the lowest dose of opioids as indicated by patient-specific risks and benefits. (Strong for)
Note: There is no absolutely safe dose of opioids.
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As opioid dosage and risk increase, we recommend more frequent monitoring for adverse events including opioid use disorder and overdose. (Strong for)
Note:
- Risks for opioid use disorder start at any dose and increase in a dose dependent manner.
- Risks for overdose and death significantly increase at a range of 20- 50 mg morphine equivalent daily dose.
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We recommend against opioid doses over 90 mg morphine equivalent daily dose for treating chronic pain. (Strong against)
Note: For patients who are currently prescribed doses over 90 mg morphine equivalent daily dose, evaluate for tapering to reduced dose or to discontinuation.
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We recommend against prescribing long-acting opioids for acute pain, as an as-needed medication, or on initiation of long-term opioid therapy. (Strong against)
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We recommend tapering to reduced dose or to discontinuation of longterm opioid therapy when risks of long-term opioid therapy outweigh benefits. (Strong for)
Note: Abrupt discontinuation should be avoided unless required for immediate safety concerns.
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We recommend individualizing opioid tapering based on risk assessment and patient needs and characteristics. (Strong for)
Note: There is insufficient evidence to recommend for or against specific tapering strategies and schedules.
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We recommend interdisciplinary care that addresses pain, substance use disorders, and/or mental health problems for patients presenting with high risk and/or aberrant behavior. (Strong for)
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We recommend offering medication assisted treatment for opioid use disorder to patients with chronic pain and opioid use disorder. (Strong for)
Note: See the VA/DoD Clinical Practice Guideline for the Management of Substance Use Disorders.
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Opioid Therapy for Acute Pain
a) We recommend alternatives to opioids for mild-to-moderate acute pain.
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b) We suggest use of multimodal pain care including non-opioid medications as indicated when opioids are used for acute pain.
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c) If take-home opioids are prescribed, we recommend that immediate-release opioids are used at the lowest effective dose with opioid therapy reassessment no later than 3-5 days to determine if adjustments or continuing opioid therapy is indicated.
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Note: Patient education about opioid risks and alternatives to opioid therapy should be offered.
Recommendation Grading
Overview
Title
Opioid Therapy (OT) for Chronic Pain
Authoring Organization
Veterans Health Administration / Department of Defense
Endorsing Organizations
American Society of Pain Educators
Centers for Disease Control and Prevention
Publication Month/Year
February 1, 2017
Last Updated Month/Year
January 17, 2024
Supplemental Implementation Tools
Document Type
Guideline
External Publication Status
Published
Country of Publication
US
Inclusion Criteria
Adolescent, Adult, Older adult
Health Care Settings
Ambulatory, Emergency care, Hospital, Medical transportation, Outpatient
Intended Users
Social worker, psychologist, addiction treatment specialist, nurse, nurse practitioner, physician, physician assistant
Scope
Assessment and screening, Diagnosis, Rehabilitation, Prevention, Management, Treatment
Diseases/Conditions (MeSH)
D059350 - Chronic Pain
Keywords
chronic pain, Urine Drug Testing, Opioid Use Disorder, acute pain, Opioid Therapy, Opioid Epidemic, Dosing Guidance
Methodology
Number of Source Documents
256
Literature Search Start Date
March 1, 2009
Literature Search End Date
December 20, 2016