Guideline for opioid therapy and chronic noncancer pain

Jason W. Busse DC PhD, Samantha Craigie MSc, David N. Juurlink MD PhD, D. Norman Buckley MD, Li Wang PhD,Rachel J. Couban MA MISt, Thomas Agoritsas MD PhD, Elie A. Akl MD PhD, Alonso Carrasco-Labra DDS MSc,
Lynn Cooper BES, Chris Cull, Bruno R. da Costa PT PhD, Joseph W. Frank MD MPH, Gus Grant AB LLB MD,Alfonso Iorio MD PhD, Navindra Persaud MD MSc, Sol Stern MD, Peter Tugwell MD MSc, Per Olav Vandvik MD PhD,
Gordon H. Guyatt MD MSc

Key Points

• We recommend optimization of nonopioid pharmacotherapy and nonpharmacologic therapy, rather than a trial of opioids, for patients with chronic noncancer pain.
• Patients with chronic noncancer pain may be offered a trial of opioids only after they have been optimized on nonopioid therapy, including nondrug measures.
• We suggest avoiding opioid therapy for patients with a history of substance use disorder (including alcohol) or active mental illness, and opioid therapy should be avoided in cases of active substance use disorder.
• For patients beginning opioid therapy, we recommend restricting to less than 90 mg morphine equivalents daily (MED) and suggest restricting the maximum prescribed dose to less than 50 mg MED.
• Patients already receiving high-dose opioid therapy (≥ 90 mg MED) should be encouraged to embark on a gradual dose taper, and multidisciplinary support should be offered where available
• to those who experience challenges.