Pain Treatment Guidelines

Dear Friends and Colleagues:
Attached a very interesting article which I received from two of our FSAM board members.
Thanks John and Michelle.
Looking forward to your comments.
Yours
Bernd
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Two professional societies released guidelines last week on opioid therapy to treat chronic, noncancer pain.

The American Pain Society and the American Academy of Pain Medicine convened a multidisciplinary panel of 21 experts to review evidence and compose 25 recommendations. The recommendations, published in the February Journal of Pain, advise providers to:

=Do a history, physical exam and appropriate testing—including a risk assessment of substance abuse—before starting a patient on chronic opioid therapy (COT);
=Consider a COT trial for patients whose pain is moderate or severe and for whom it has an adverse impact on function or quality of life;
=Reassess patients on COT periodically, with monitoring to include documenting pain and functioning levels, adherence, and presence of adverse events;
=Use COT on patients with a history of drug abuse or psychiatric issues only if they can be monitored more frequently and strictly;
=Do periodic urine drug screens on patients at high risk or who engaged in drug-related behavior in the past, and possibly on patients who aren't high-risk, too; and
=Evaluate health status, adherence and side effects on an ongoing basis in patients on high doses of COT, and consider more follow-up visits.

On a related note, FDA last week sent letters to opioid manufacturers asking them to develop plans to reduce the misuse of their drugs, the Feb. 9 Washington Post reported. The plans, which are meant to help reduce the rising incidence of overdose and abuse, might include enhanced warnings on labels or restricting the kinds of patients who can use the drugs, the Post said. A list of affected drugs, most of which are high dose and/or extended release, is online.

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Article Abstract
The Journal of Pain, Volume 10, Issue 2, Pages 113-130.e22 (February 2009)

Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain

Roger Chou1, Gilbert J. Fanciullo2, Perry G. Fine3, Jeremy A. Adler4, Jane C. Ballantyne5, Pamela Davies6, Marilee I. Donovan7, David A. Fishbain8, Kathy M. Foley9, Jeffrey Fudin10, Aaron M. Gilson11, Alexander Kelter12, Alexander Mauskop13, Patrick G. O'Connor14, Steven D. Passik15, Gavril W. Pasternak16, Russell K. Portenoy17, Ben A. Rich18, Richard G. Roberts19, Knox H. Todd20, Christine Miaskowski21, American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel
Abstract
Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.

Perspective

Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.

Link to full article: http://www.jpain.org/article/PIIS1526590008008316/fulltext