Results:
Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for
initiating and maintaining chronic opioid therapy of 90 days or longer.
1. A) Comprehensive assessment and documentation is recommended before initiating opioid
therapy, including documentation of comprehensive history, general medical condition,
psychosocial history, psychiatric status, and substance use history. (Evidence: good)
B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended,
as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited)
C) Prescription monitoring programs must be implemented, as they provide data on patterns of
prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair)
D) Urine drug testing (UDT) must be implemented from initiation along with subsequent
adherence monitoring to decrease prescription drug abuse or illicit drug use when patients
are in chronic pain management therapy. (Evidence: good)
2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to
initiating opioid therapy. (Evidence: good)
B) Caution must be exercised in ordering various imaging and other evaluations, interpretation
and communication with the patient; to avoid increased fear, activity restriction, requests for
increased opioids, and maladaptive behaviors. (Evidence: good)
C) Stratify patients into one of the 3 risk categories – low, medium, or high risk.
D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy
is utilized. (Evidence: fair)
3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy.
(Evidence: good)
4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function.
(Evidence: good)
5. A) Long-acting opioids in high doses are recommended only in specific circumstances with
severe intractable pain that is not amenable to short-acting or moderate doses of long-acting
opioids, as there is no significant difference between long-acting and short-acting opioids for
their effectiveness or adverse effects. (Evidence: fair)
B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be
evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide
risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active
diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence:
fair to limited)
6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements
reduce overuse, misuse, abuse, and diversion. (Evidence: fair)
7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with
appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness,
limited for long-term effectiveness)
B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose,
and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair)
C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided.
(Evidence: good)
8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific
training in the risks and uses. (Evidence: limited)
B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to
initiation, at 30 days and yearly thereafter. (Evidence: fair)
9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence
that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs.
(Evidence: fair)
10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good)
11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction
with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse
effects. (Evidence: fair)
Disclaimer: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations.
Due to the changing body of evidence, this document is not intended to be a “standard of care.”
Key words: Chronic pain, persistent pain, non-cancer pain, controlled substances, substance abuse, prescription drug abuse,
dependency, opioids, prescription monitoring, drug testing, adherence monitoring, diversion
A pediatric cancer patient with suspected chemical coping following high-dose opioid therapy: a case report
