Past Issue - July 2012 - Vol 15 Issue 3S Index | Previous | Next | 
2012; 15;S67-S116. American Society of Interventional Pain Physicians (ASIPP) Guidelines for Responsible Opioid Prescribing in Chronic Non-Cancer Pain: Part 2 - Guidance
Guidelines
Laxmaiah Manchikanti, MD, Salahadin Abdi, MD, PhD, Sairam Atluri, MD, Carl C Balog, MD, Ramsin M. Benyamin, MD, Mark V. Boswell, MD, PhD, Keith R Brown, PharmD, Brian M. Bruel, MD, David A. Bryce, MD, Patricia A Burks, LPT, Allen W. Burton, MD, Aaron K. Calodney, MD, David L. Caraway, MD, Kimberly A. Cash, RT, Paul J. Christo, MD, Kim S. Damron, RN, Sukdeb Datta, MD, Timothy R. Deer, MD, Sudhir Diwan, MD, Ike Eriator, MD, Frank J.E. Falco, MD, Bert Fellows, MA, Stephanie Geffert, MLIS, Christopher G. Gharibo, MD, Scott E. Glaser, MD, Jay S. Grider, DO, PhD, Haroon Hameed, MD, Mariam Hameed, MD, Hans Hansen, MD, Michael E. Harned, MD, Salim M. Hayek, MD, PhD, Standiford Helm II, MD, Joshua A. Hirsch, MD, Jeffrey W Janata, PhD, Alan D Kaye, MD, PhD, Adam M Kaye, PharmD, David S. Kloth, MD, Dhanalakshmi Koyyalagunta, MD, Marion Lee, MD, Yogesh Malla, MD, Kavita N. Manchikanti, MD, Carla D. McManus, RN, BSN, Vidyasagar Pampati, MSc, Allan T. Parr, MD, Ramarao Pasupuleti, MD, Vikram B. Patel, MD, Nalini Sehgal, MD, Sanford M. Silverman, MD, Vijay Singh, MD, Howard S. Smith, MD, Lee T Snook, MD, Daneshvari R. Solanki, MD, Deborah H Tracy, MD, Ricardo Vallejo, MD, PhD, and Bradley W. Wargo, DO
 

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.”

 

   
 
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Pain Physcian
Authors
Bradley W. Wargo
Ricardo Vallejo
Deborah H Tracy
Daneshvari R. Solanki
Lee T Snook
Howard S. Smith
Vijay Singh
Sanford M. Silverman
Nalini Sehgal
Vikram B. Patel
Ramarao Pasupuleti
Allan T. Parr
Vidyasagar Pampati
Carla D. McManus
Kavita N. Manchikanti
Yogesh Malla
Marion Lee
Dhanalakshmi Koyyalagunta
David S. Kloth
Adam M Kaye
Alan D Kaye
Jeffrey W Janata
Joshua A. Hirsch
Standiford Helm II
Salim M. Hayek
Michael E. Harned
Hans Hansen
Mariam Hameed
Haroon Hameed
Jay S. Grider
Scott E. Glaser
Christopher G. Gharibo
Stephanie Geffert
Bert Fellows
Frank J.E. Falco
Ike Eriator
Sudhir Diwan
Timothy R. Deer
Sukdeb Datta
Kim S. Damron
Paul J. Christo
Kimberly A. Cash
David L. Caraway
Aaron K. Calodney
Allen W. Burton
Patricia A Burks
David A. Bryce
Brian M. Bruel
Keith R Brown
Mark V. Boswell
Ramsin M. Benyamin
Carl C Balog
Sairam Atluri
Salahadin Abdi
Laxmaiah Manchikanti


Keywords
Chronic pain
persistent pain
non-cancer pain
controlled substances
substance abuse
prescription drug abuse
dependency
opioids
prescription monitoring
drug testing
adherence monitoring
diversion