1. 2014;17;401-414Chronic Opioid Therapy for Chronic Non-Cancer Pain: A Review and Comparison of Treatment Guidelines
   Comprehensive Review
   Chi Wai Cheung, MD, Qiu Qiu, MD, Siu-Wai Choi, PhD, Brendan Moore, MBBS, Roger Goucke, MBBS, and Michael Irwin, MD.

BACKGROUND: Long-term opioid use for chronic non-cancer pain has increased substantially in recent years despite the paucity of strong supporting scientific data and concerns regarding adverse effects and potential misuse.

STUDY DESIGN: Review and summary of practice guidelines available on PubMed and Cochrane databases as well as on the Internet on chronic opioid therapy from June 2004 to June 2013.

OBJECTIVE: To review expert-developed practice guidelines on chronic opioid therapy, published in different countries over the past decade in order to reveal similar principles of therapy and to provide useful information and references for future development of opioid guidelines to identify adequately supported practice points and areas in need of further scientific evidence.

METHOD: Seven guidelines were identified as pertaining specifically to the long-term use of opioids for general chronic non-cancer pain from an initial search of the PubMed/Medline and Cochrane databases using combinations of the search terms “opioid,”  “chronic opioid therapy,” “chronic pain,” “chronic non-cancer pain,” “chronic non-malignant pain,” “guidelines,” “practice guidelines,” and “clinical practice guidelines,” filtered to include only articles on humans published in the English language over the past 10 years.

RESULTS: All guidelines espouse an individual approach to management, beginning with a comprehensive patient evaluation, with particular focus on eliciting factors that may indicate potential drug misuse and abuse, and a trial of therapy to determine the course of treatment. Goals of treatment should be adequately discussed with and consented to by the patient. Opioids are generally not recommended as first-line therapy but, when used, clinicians should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing (UDT) may be used as a tool to monitor for aberrant behavior or drug misuse; opioid rotation may be considered when loss of response or adverse effects are a concern, at a starting dose lower than the calculated equianalgesic dose.

LIMITATIONS: Information on some African nations, countries in the Middle-East, and Pacific Islands is not available and therefore was not included in this review.

CONCLUSION: There is a growing body of scientific evidence to support opioid use in chronic pain. Future work should focus on continuing to generate good-quality evidence on the long-term benefits of opioid therapy, as well as scientific data to guide drug choice and dosing for specific conditions, populations, and situations.