This JAMA Insights Clinical Update reviews evidence-based use of opioids to manage noncancer pain, proposing opioid-sparing pain management. Based on recent literature and the rapidly evolving nature of the opioid overdose epidemic due to the emergence of fentanyl analogues in the illicit drug supply, there are clearly 3 main clinical scenarios being confronted by clinicians where evidence-based recommendations can be made.
1- chronic pain management (excl. cancer, palliative or other special pain) not on opioid therapy
The first clinical scenario is the approach to take for chronic pain patients (excluding cancer, palliative or other special circumstances) not on opioid therapy. Here, the literature suggests that opioid therapy should be avoided given the limited likelihood of benefit and the major evidence of opioid-related harms. The efforts to use the clinical examination or screening tools to identify low risk patients don’t have much value.
2- chronic pain patients already on opioid therapy
The second clinical scenario is the approach to take with chronic pain patients already on opioid therapy. Here, individualized care is warranted. Although the literature suggests potential for improved pain and functioning with opioid tapering, this must be balanced with the risks of exacerbating pain, opioid withdrawal syndrome. Withholding opioid therapies may result in transition to street opioid use. There is a high prevalence and risks associated with prescription opioid diversion and misuse. Opioid agonist therapy (OAT) has proved benefits in the prescription opioid addiction context. Buprenorphine/ naloxone may provide similar analgesia as full opioid agonists.Therefore, OAT should be increasingly considered in this context. This will require that efforts to overcome barriers to OAT be redoubled.
3- acute pain management
The third clinical scenario is the approach to take in acute pain contexts. Most chronic pain initially presents as acute pain. The benefits of opioids on acute pain may diminish rather quickly. There are known risks of prolonged opioid prescription and dose on risk of subsequent opioid addiction. Therefore, opioid therapy should be avoided in those with minor to moderate acute pain, and when opioids are used in severe acute pain, the dose and duration limited to short (e.g., < 1 week), renewable (if necessary) courses.
Wood E, Simel DL, Klimas J. Pain Management With Opioids in 2019-2020. JAMA. Published online October 10, 2019. doi:https://doi.org/10.1001/jama.2019.15802
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