Determining When to Initiate or Continue Opioids for Chronic Pain
- Use opioids only when benefits outweigh risks, and combine with non-opioid drugs and non-pharmacologic treatments when appropriate.
- Establish realistic treatment goals, with a plan for discontinuation.
- Discuss risks, benefits, and responsibilities with the patient.
Opioid Selection, Dosage, Duration, Follow-Up, and Discontinuation
- Begin with immediate-release opioids.
- Begin with the lowest effective dosage, and assess risks and benefits before increasing.
- Three days or less will often be sufficient for acute pain, and more than 7 days will rarely be needed.
- For chronic pain, reevaluate within 1-4 weeks of starting therapy or escalating dose, and then at least every 3 months.
Assessing Risk and Addressing Harms of Opioid Use
- Incorporate risk mitigation strategies into the treatment plan, including consideration of naloxone when overdose risk is elevated.
- Review Prescription Drug Monitoring Program (PDMP) data to help determine risk for the individual patient.
- For chronic pain, get a urine drug test before starting opioid therapy, and consider repeating at least annually.
- Avoid prescribing opioids and benzodiazepines together whenever possible.
- Arrange treatment for patients with opioid use disorder.