Chronic opioid therapy for non-cancer pain and safe tapering

What it is

The increase in opiate-related accidental overdoses has become a significant concern in recent years, prompting the CDC to release updated guidelines for the use of narcotic medications for chronic noncancer pain. Opioids should not be used as first-line therapy for chronic noncancer pain, a Choosing Wisely recommendation from the American Society of Anesthesiologists. The CDC recommends that chronic noncancer pain be primarily treated with nonpharmacologic and nonopiate medications, and that the use of opioids be reserved for recalcitrant cases under close supervision, at the lowest effective dose and for the shortest time possible.

How it is treated

Two conditions are named in which opiates are recommended against: fibromyalgia and neuropathy, because of limited efficacy and side-effect profiles. The concurrent use of opiates and benzodiazepines should be avoided in nearly all situations. Safety should never be compromised for reduced pain and increased functionality.

Once opioids are started they tend to stay. More than one-half of patients who receive continuous opioids for 90 days are still receiving them after 4 years. Controlled substance prescribing plans are considered good practice for long-term opioid use.

Chronic opioids should not be abruptly discontinued. When discontinuing chronic opioid therapy, the best practice is to reduce the dosage by 5% to 10% every 1 to 4 weeks, and even this may be too fast for some patients. While the dose is being tapered, weekly urine drug screens would continue to be positive, so they are not an appropriate management strategy at that stage.