Chronic pain, defined as persistent pain lasting longer than 12 weeks, affects approximately 20% of US adults and often results in mental and social burdens. In general, nonopioid therapies are preferred for chronic nonterminal pain, and opioid therapy should not be considered a first-line treatment modality. Health disparities in pain management affect vulnerable populations, including racially and ethnically marginalized groups and those with cognitive impairment. Clinicians first must acknowledge the existing health inequities and the stigma surrounding chronic pain and then need to provide culturally tailored pain management. Opioid use should be limited to circumstances wherein benefits outweigh risks, such as in cases of nonterminal pain refractory to multiple other interventions. Harms of opioid therapy include constipation, depression, hormonal dysregulation, opioid-induced hyperalgesia, and overdose. Given the high prevalence of behavioral health disorders in individuals with chronic pain, it is crucial to address mental health in conjunction with pain management. Before prescribing opioids, it is essential to review risk factors for opioid use disorder and respiratory depression and to set realistic goals for improving function. Ongoing monitoring should include assessments of functional progress, urine drug testing, and review of data from the state prescription drug monitoring program. Buprenorphine is an effective medication for chronic pain management and may be safer than full opioid agonists, especially in individuals at risk for opioid use disorder, opioid misuse, or overdose.
Chronic pain, defined as persistent pain lasting beyond 12 weeks, affects approximately 20% of US adults and increases the risk of depression, anxiety, productivity loss, and financial burden.1–3 Among adults with chronic pain, 22.1% report using a prescription opioid in the past 3 months, with the highest prevalence (25.9%) in patients 45 to 64 years of age.4 Although national prescription opioid use has declined by one-half in the past decade, prescription opioids led to approximately 294,000 overdose deaths between 1999 and 2022 in the United States.5,6 Family physicians face multiple challenges, including a sense of ineffectiveness at managing chronic pain, the emotional burden of difficult discussions, and the need to address patient expectations.7,8 This article aims to assist family physicians in navigating discussions about long-term opioid therapy for pain due to nonterminal conditions. Table 1 shows terms and definitions commonly used regarding long-term opioid therapy.9,10
WHAT'S NEW ON THIS TOPIC
| Although national prescription opioid use has declined by one-half in the past decade, prescription opioids led to approximately 294,000 overdose deaths between 1999 and 2022 in the United States. |
| Compared with White individuals, people of color are less likely to receive appropriate analgesics and are more likely to have long-term opioid therapy discontinued following illicit drug use. |
| A systematic review and meta-analysis of 96 randomized controlled trials of long-term opioid therapy for chronic noncancer pain showed small but statistically significant improvements in pain, physical function, and sleep quality. |
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
| Opioid therapy is not first-line treatment for chronic nonterminal pain and should be limited to circumstances in which benefits outweigh risks.11,17 | C | Expert consensus guidelines |
| To minimize precipitated opioid withdrawal, clinicians should slowly taper opioids rather than rapidly tapering or abruptly discontinuing them.11 | C | Expert consensus guidelines |
| Realistic goals for function, pain, and quality of life should be explicitly discussed and clearly documented throughout the course of long-term opioid therapy.11 | C | Expert consensus guidelines |
| Clinicians may consider rotating from a full opioid agonist to a partial opioid agonist (buprenorphine) for nonterminal pain management, especially in people with opioid use disorder or those who are at risk for opioid misuse or overdose.29,42,43 | C | Expert consensus guidelines |
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 https://www.aafp.org/afpsort.
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