Weighing the Risks and Benefits of Chronic Opioid Therapy

 

Evidence supports the use of opioids for treating acute pain. However, the evidence is limited for the use of chronic opioid therapy for chronic pain. Furthermore, the risks of chronic therapy are significant and may outweigh any potential benefits. When considering chronic opioid therapy, physicians should weigh the risks against any possible benefits throughout the therapy, including assessing for the risks of opioid misuse, opioid use disorder, and overdose. When initiating opioid therapy, physicians should consider buprenorphine for patients at risk of opioid misuse, opioid use disorder, and overdose. If and when opioid misuse is detected, opioids do not necessarily need to be discontinued, but misuse should be noted on the problem list and interventions should be performed to change the patient's behavior. If aberrant behavior continues, opioid use disorder should be diagnosed and treated accordingly. When patients are discontinuing opioid therapy, the dosage should be decreased slowly, especially in those who have intolerable withdrawal. It is not unreasonable for discontinuation of chronic opioid therapy to take many months. Benzodiazepines should not be coprescribed during chronic opioid therapy or when tapering, because some patients may develop cross-dependence. For patients at risk of overdose, naloxone should be offered to the patient and to others who may be in a position to witness and reverse opioid overdose.

Opioid analgesics have historically been prescribed for acute trauma, perioperative care, cancer pain, and pain associated with life-limiting illness. Over the past several decades, opioids have been increasingly dispensed chronically for many nonacute conditions. More than one-half of patients who receive continuous opioid therapy for 90 days are still receiving opioids more than four years later.1 By sheer volume, family physicians prescribe more opioid analgesics than any other subspecialists.2

WHAT IS NEW ON THIS TOPIC: CHRONIC OPIOID THERAPY

The Centers for Disease Control and Prevention recently published new guidelines on prescribing opioids for chronic pain ( http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm).

Clinicians should perform ongoing risk-benefit assessments throughout the course of chronic opioid therapy because problems can arise at any time. Patients receiving chronic opioid therapy should be reevaluated at least every three months—even when stable and doing well—and more frequently if problems arise.

View/Print Table

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Consider buprenorphine formulations as an alternative to other opioids to treat chronic pain in patients at increased risk of opioid misuse, opioid use disorder, or overdose.

C

16

Pain that progresses despite chronic opioid therapy may represent opioid-induced hyperalgesia. Taper the opioid and wait until acute withdrawal resolves before reassessing pain. Inform the patient that opioid withdrawal is associated with physical pain, and does not necessarily represent progression of the underlying disease.

C

2428

When opioid misuse is detected, do not terminate the patient from your practice or refuse to prescribe further opioid therapy. Instead, add opioid misuse to your problem list and intervene to change the patient's behavior. If aberrant behavior resolves, reward course correction. If aberrant behavior continues, consider the diagnosis of opioid use disorder and treat (or refer) accordingly.

C

2934

Offer naloxone to patients at risk of opioid overdose.

C

3537

To mitigate the risk of overdose, do not prescribe benzodiazepines concurrently with chronic opioid therapy. Also, avoid benzodiazepine coprescribing as treatment for opioid withdrawal, especially in patients with opioid misuse or opioid use disorder.

C

10, 15, 35, 36, 3841

When discontinuing opioids, decrease the dosage slowly, especially in patients who experience intolerable withdrawal. Standard recommendations to decrease the dosage by 5% to 10% of the starting dosage every one to four weeks may still be too fast for some patients, especially those on long-term high dosages. Some patients may need to decrease by as little as 5% or less every two to three months, with even smaller decrements toward the end of the taper. It is not unreasonable to take many months to wean some patients off chronic opioid therapy.

C

60


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Consider buprenorphine formulations as an alternative to other opioids to treat chronic pain in patients at increased risk of opioid misuse, opioid use disorder, or overdose.

C

16

Pain that progresses despite chronic opioid therapy

The Authors

show all author info

ANNA LEMBKE, MD, is an assistant professor and director of the Stanford Addiction Medicine Program in the Department of Psychiatry and Behavioral Sciences at Stanford (Calif.) University School of Medicine....

KEITH HUMPHREYS, PhD, is a professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine, and a professor at the Center for Innovation to Implementation at the Veterans Affairs Health Care System, Menlo Park, Calif.

JORDAN NEWMARK, MD, is a clinical assistant professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine.

Dr. Lembke would like to acknowledge support from the Peter F. McManus Charitable Trust. Dr. Humphreys would like to acknowledge support from the Veterans Affairs Health Services Research and Development Service.

Address correspondence to Anna Lembke, MD, Stanford University School of Medicine, 401 Quarry Rd., Stanford, CA 94305 (e-mail: alembke@stanford.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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