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Opioids for pain

What's new

Updated 2023 ASIPP guidelines on opioid use in chronic non-cancer pain.

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of opioids for pain are prepared by our editorial team based on guidelines from the American Society of Interventional Pain Physicians (ASIPP 2023), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the American Society of Clinical Oncology (ASCO 2022), the Center for Disease Control (CDC 2022), the ...
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Diagnostic investigations

Clinical assessment: as per ASIPP 2023 guidelines, obtain a comprehensive evaluation of pain history, medical history, psychosocial history, functional assessment, and appropriate consultations before initiating opioid therapy.
A
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  • Review of prescriptions

  • Screening for substance abuse

  • Genetic testing

Medical management

Indications for initiation
As per ASCO 2022 guidelines:
Initiate opioids in patients with moderate-to-severe pain related to cancer or active cancer treatment, unless contraindicated.
B
Discuss goals regarding functional outcomes, shared expectations, and pain intensity, as well as any concerns about opioids before initiating opioid therapy.
A

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  • Choice of agent and dosage

  • Tapering and discontinuation

  • Non-opioid therapies

  • Antiemetic prophylaxis

Perioperative care

Preoperative counseling: as per DoD/VA 2022 guidelines, consider providing patients with preoperative opioid and pain management education to decrease the risk of prolonged opioid use for postoperative pain.
C

Specific circumstances

Patients with postoperative pain: as per AAST/GAIS/SIAARTI/WSES 2022 guidelines, administer a major opioid for the treatment of moderate-to-severe pain unresponsive to other medications, if regional anesthesia techniques are not indicated.
B
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  • Patients with opioid use disorder

  • Patients with substance use disorder

  • Patients with renal/hepatic impairment

  • Patients with opioid-induced constipation

Patient education

Pretreatment counseling: as per ASIPP 2023 guidelines, discuss the realistic benefits and known risks of opioids with patients before initiating opioid therapy. Establish clear treatment goals for pain and/or function discussing how opioid therapy will be discontinued if benefits do not outweigh risks.
A
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Follow-up and surveillance

Clinical monitoring: as per ASIPP 2023 guidelines, assess meaningful benefit (at least 30% benefit in pain and/or function) produced by opioid therapy and ensure that opioid therapy does not incur aberrant behaviors and/or adverse effects.
B
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  • Urine drug monitoring