American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain

Part 2--guidance.

Laxmaiah Manchikanti, Salahadin Abdi, Sairam Atluri, Carl C. Balog, Ramsin M. Benyamin, Mark V. Boswell, Keith R. Brown, Brian M. Bruel, David A. Bryce, Patricia A. Burks, Allen W. Burton, Aaron K. Calodney, David L. Caraway, Kimberly A. Cash, Paul J. Christo, Kim S. Damron, Sukdeb Datta, Timothy R. Deer, Sudhir Diwan, Ike Eriator & 36 others Frank J E Falco, Bert Fellows, Stephanie Geffert, Christopher G. Gharibo, Scott E. Glaser, Jay S. Grider, Haroon Hameed, Mariam Hameed, Hans Hansen, Michael E. Harned, Salim M. Hayek, Standiford Helm, Joshua A. Hirsch, Jeffrey W. Janata, Alan D. Kaye, Adam M. Kaye, David S. Kloth, Dhanalakshmi Koyyalagunta, Marion Lee, Yogesh Malla, Kavita N. Manchikanti, Carla D. McManus, Vidyasagar Pampati, Allan T. Parr, Ramarao Pasupuleti, Vikram B. Patel, Nalini Sehgal, Sanford M. Silverman, Vijay Singh, Howard S. Smith, Lee T. Snook, Daneshvari R. Solanki, Deborah H. Tracy, Ricardo Vallejo, Bradley W. Wargo, Society of Interventional Pain Physicians American Society of Interventional Pain Physicians

Research output: Contribution to journalArticle

264 Citations (Scopus)

Abstract

RESULTS: Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (Evidence: good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (Evidence: good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (Evidence: good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (Evidence: good) C) Stratify patients into one of the 3 risk categories - low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (Evidence: fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (Evidence: good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (Evidence: fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence: fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (Evidence: fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (Evidence: good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (Evidence: limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (Evidence: fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (Evidence: fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (Evidence: fair). DISCLAIMER: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."

Original languageEnglish (US)
JournalPain Physician
Volume15
Issue number3 Suppl
StatePublished - Jul 2012
Externally publishedYes

Fingerprint

Opioid Analgesics
Guidelines
Physicians
Pain
Prescription Drug Misuse
Therapeutics
Morphine
Prescriptions
Methadone
Street Drugs
Pain Management
Documentation
Prescription Drug Diversion
Psychiatry
History
Urine
Central Nervous System Depressants
Pharmaceutical Preparations
Intractable Pain
Prescription Drugs

ASJC Scopus subject areas

  • Anesthesiology and Pain Medicine

Cite this

Manchikanti, L., Abdi, S., Atluri, S., Balog, C. C., Benyamin, R. M., Boswell, M. V., ... American Society of Interventional Pain Physicians, S. O. I. P. P. (2012). American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance. Pain Physician, 15(3 Suppl).

American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain : Part 2--guidance. / Manchikanti, Laxmaiah; Abdi, Salahadin; Atluri, Sairam; Balog, Carl C.; Benyamin, Ramsin M.; Boswell, Mark V.; Brown, Keith R.; Bruel, Brian M.; Bryce, David A.; Burks, Patricia A.; Burton, Allen W.; Calodney, Aaron K.; Caraway, David L.; Cash, Kimberly A.; Christo, Paul J.; Damron, Kim S.; Datta, Sukdeb; Deer, Timothy R.; Diwan, Sudhir; Eriator, Ike; Falco, Frank J E; Fellows, Bert; Geffert, Stephanie; Gharibo, Christopher G.; Glaser, Scott E.; Grider, Jay S.; Hameed, Haroon; Hameed, Mariam; Hansen, Hans; Harned, Michael E.; Hayek, Salim M.; Helm, Standiford; Hirsch, Joshua A.; Janata, Jeffrey W.; Kaye, Alan D.; Kaye, Adam M.; Kloth, David S.; Koyyalagunta, Dhanalakshmi; Lee, Marion; Malla, Yogesh; Manchikanti, Kavita N.; McManus, Carla D.; Pampati, Vidyasagar; Parr, Allan T.; Pasupuleti, Ramarao; Patel, Vikram B.; Sehgal, Nalini; Silverman, Sanford M.; Singh, Vijay; Smith, Howard S.; Snook, Lee T.; Solanki, Daneshvari R.; Tracy, Deborah H.; Vallejo, Ricardo; Wargo, Bradley W.; American Society of Interventional Pain Physicians, Society of Interventional Pain Physicians.

In: Pain Physician, Vol. 15, No. 3 Suppl, 07.2012.

Research output: Contribution to journalArticle

Manchikanti, L, Abdi, S, Atluri, S, Balog, CC, Benyamin, RM, Boswell, MV, Brown, KR, Bruel, BM, Bryce, DA, Burks, PA, Burton, AW, Calodney, AK, Caraway, DL, Cash, KA, Christo, PJ, Damron, KS, Datta, S, Deer, TR, Diwan, S, Eriator, I, Falco, FJE, Fellows, B, Geffert, S, Gharibo, CG, Glaser, SE, Grider, JS, Hameed, H, Hameed, M, Hansen, H, Harned, ME, Hayek, SM, Helm, S, Hirsch, JA, Janata, JW, Kaye, AD, Kaye, AM, Kloth, DS, Koyyalagunta, D, Lee, M, Malla, Y, Manchikanti, KN, McManus, CD, Pampati, V, Parr, AT, Pasupuleti, R, Patel, VB, Sehgal, N, Silverman, SM, Singh, V, Smith, HS, Snook, LT, Solanki, DR, Tracy, DH, Vallejo, R, Wargo, BW & American Society of Interventional Pain Physicians, SOIPP 2012, 'American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance.', Pain Physician, vol. 15, no. 3 Suppl.
Manchikanti, Laxmaiah ; Abdi, Salahadin ; Atluri, Sairam ; Balog, Carl C. ; Benyamin, Ramsin M. ; Boswell, Mark V. ; Brown, Keith R. ; Bruel, Brian M. ; Bryce, David A. ; Burks, Patricia A. ; Burton, Allen W. ; Calodney, Aaron K. ; Caraway, David L. ; Cash, Kimberly A. ; Christo, Paul J. ; Damron, Kim S. ; Datta, Sukdeb ; Deer, Timothy R. ; Diwan, Sudhir ; Eriator, Ike ; Falco, Frank J E ; Fellows, Bert ; Geffert, Stephanie ; Gharibo, Christopher G. ; Glaser, Scott E. ; Grider, Jay S. ; Hameed, Haroon ; Hameed, Mariam ; Hansen, Hans ; Harned, Michael E. ; Hayek, Salim M. ; Helm, Standiford ; Hirsch, Joshua A. ; Janata, Jeffrey W. ; Kaye, Alan D. ; Kaye, Adam M. ; Kloth, David S. ; Koyyalagunta, Dhanalakshmi ; Lee, Marion ; Malla, Yogesh ; Manchikanti, Kavita N. ; McManus, Carla D. ; Pampati, Vidyasagar ; Parr, Allan T. ; Pasupuleti, Ramarao ; Patel, Vikram B. ; Sehgal, Nalini ; Silverman, Sanford M. ; Singh, Vijay ; Smith, Howard S. ; Snook, Lee T. ; Solanki, Daneshvari R. ; Tracy, Deborah H. ; Vallejo, Ricardo ; Wargo, Bradley W. ; American Society of Interventional Pain Physicians, Society of Interventional Pain Physicians. / American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain : Part 2--guidance. In: Pain Physician. 2012 ; Vol. 15, No. 3 Suppl.
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title = "American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance.",
abstract = "RESULTS: Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (Evidence: good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (Evidence: good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (Evidence: good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (Evidence: good) C) Stratify patients into one of the 3 risk categories - low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (Evidence: fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (Evidence: good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (Evidence: fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence: fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (Evidence: fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (Evidence: good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (Evidence: limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (Evidence: fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (Evidence: fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (Evidence: fair). DISCLAIMER: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a {"}standard of care.{"}",
author = "Laxmaiah Manchikanti and Salahadin Abdi and Sairam Atluri and Balog, {Carl C.} and Benyamin, {Ramsin M.} and Boswell, {Mark V.} and Brown, {Keith R.} and Bruel, {Brian M.} and Bryce, {David A.} and Burks, {Patricia A.} and Burton, {Allen W.} and Calodney, {Aaron K.} and Caraway, {David L.} and Cash, {Kimberly A.} and Christo, {Paul J.} and Damron, {Kim S.} and Sukdeb Datta and Deer, {Timothy R.} and Sudhir Diwan and Ike Eriator and Falco, {Frank J E} and Bert Fellows and Stephanie Geffert and Gharibo, {Christopher G.} and Glaser, {Scott E.} and Grider, {Jay S.} and Haroon Hameed and Mariam Hameed and Hans Hansen and Harned, {Michael E.} and Hayek, {Salim M.} and Standiford Helm and Hirsch, {Joshua A.} and Janata, {Jeffrey W.} and Kaye, {Alan D.} and Kaye, {Adam M.} and Kloth, {David S.} and Dhanalakshmi Koyyalagunta and Marion Lee and Yogesh Malla and Manchikanti, {Kavita N.} and McManus, {Carla D.} and Vidyasagar Pampati and Parr, {Allan T.} and Ramarao Pasupuleti and Patel, {Vikram B.} and Nalini Sehgal and Silverman, {Sanford M.} and Vijay Singh and Smith, {Howard S.} and Snook, {Lee T.} and Solanki, {Daneshvari R.} and Tracy, {Deborah H.} and Ricardo Vallejo and Wargo, {Bradley W.} and {American Society of Interventional Pain Physicians}, {Society of Interventional Pain Physicians}",
year = "2012",
month = "7",
language = "English (US)",
volume = "15",
journal = "Pain Physician",
issn = "1533-3159",
publisher = "Association of Pain Management Anesthesiologists",
number = "3 Suppl",

}

TY - JOUR

T1 - American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain

T2 - Part 2--guidance.

AU - Manchikanti, Laxmaiah

AU - Abdi, Salahadin

AU - Atluri, Sairam

AU - Balog, Carl C.

AU - Benyamin, Ramsin M.

AU - Boswell, Mark V.

AU - Brown, Keith R.

AU - Bruel, Brian M.

AU - Bryce, David A.

AU - Burks, Patricia A.

AU - Burton, Allen W.

AU - Calodney, Aaron K.

AU - Caraway, David L.

AU - Cash, Kimberly A.

AU - Christo, Paul J.

AU - Damron, Kim S.

AU - Datta, Sukdeb

AU - Deer, Timothy R.

AU - Diwan, Sudhir

AU - Eriator, Ike

AU - Falco, Frank J E

AU - Fellows, Bert

AU - Geffert, Stephanie

AU - Gharibo, Christopher G.

AU - Glaser, Scott E.

AU - Grider, Jay S.

AU - Hameed, Haroon

AU - Hameed, Mariam

AU - Hansen, Hans

AU - Harned, Michael E.

AU - Hayek, Salim M.

AU - Helm, Standiford

AU - Hirsch, Joshua A.

AU - Janata, Jeffrey W.

AU - Kaye, Alan D.

AU - Kaye, Adam M.

AU - Kloth, David S.

AU - Koyyalagunta, Dhanalakshmi

AU - Lee, Marion

AU - Malla, Yogesh

AU - Manchikanti, Kavita N.

AU - McManus, Carla D.

AU - Pampati, Vidyasagar

AU - Parr, Allan T.

AU - Pasupuleti, Ramarao

AU - Patel, Vikram B.

AU - Sehgal, Nalini

AU - Silverman, Sanford M.

AU - Singh, Vijay

AU - Smith, Howard S.

AU - Snook, Lee T.

AU - Solanki, Daneshvari R.

AU - Tracy, Deborah H.

AU - Vallejo, Ricardo

AU - Wargo, Bradley W.

AU - American Society of Interventional Pain Physicians, Society of Interventional Pain Physicians

PY - 2012/7

Y1 - 2012/7

N2 - RESULTS: Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (Evidence: good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (Evidence: good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (Evidence: good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (Evidence: good) C) Stratify patients into one of the 3 risk categories - low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (Evidence: fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (Evidence: good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (Evidence: fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence: fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (Evidence: fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (Evidence: good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (Evidence: limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (Evidence: fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (Evidence: fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (Evidence: fair). DISCLAIMER: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."

AB - RESULTS: Part 2 of the guidelines on responsible opioid prescribing provides the following recommendations for initiating and maintaining chronic opioid therapy of 90 days or longer. 1. A) Comprehensive assessment and documentation is recommended before initiating opioid therapy, including documentation of comprehensive history, general medical condition, psychosocial history, psychiatric status, and substance use history. (Evidence: good) B) Despite limited evidence for reliability and accuracy, screening for opioid use is recommended, as it will identify opioid abusers and reduce opioid abuse. (Evidence: limited) C) Prescription monitoring programs must be implemented, as they provide data on patterns of prescription usage, reduce prescription drug abuse or doctor shopping. (Evidence: good to fair) D) Urine drug testing (UDT) must be implemented from initiation along with subsequent adherence monitoring to decrease prescription drug abuse or illicit drug use when patients are in chronic pain management therapy. (Evidence: good) 2. A) Establish appropriate physical diagnosis and psychological diagnosis if available prior to initiating opioid therapy. (Evidence: good) B) Caution must be exercised in ordering various imaging and other evaluations, interpretation and communication with the patient, to avoid increased fear, activity restriction, requests for increased opioids, and maladaptive behaviors. (Evidence: good) C) Stratify patients into one of the 3 risk categories - low, medium, or high risk. D) A pain management consultation, may assist non-pain physicians, if high-dose opioid therapy is utilized. (Evidence: fair) 3. Essential to establish medical necessity prior to initiation or maintenance of opioid therapy. (Evidence: good) 4. Establish treatment goals of opioid therapy with regard to pain relief and improvement in function. (Evidence: good) 5. A) Long-acting opioids in high doses are recommended only in specific circumstances with severe intractable pain that is not amenable to short-acting or moderate doses of long-acting opioids, as there is no significant difference between long-acting and short-acting opioids for their effectiveness or adverse effects. (Evidence: fair) B) The relative and absolute contraindications to opioid use in chronic non-cancer pain must be evaluated including respiratory instability, acute psychiatric instability, uncontrolled suicide risk, active or history of alcohol or substance abuse, confirmed allergy to opioid agents, coadministration of drugs capable of inducing life-limiting drug interaction, concomitant use of benzodiazepines, active diversion of controlled substances, and concomitant use of heavy doses of central nervous system depressants. (Evidence: fair to limited) 6. A robust agreement which is followed by all parties is essential in initiating and maintaining opioid therapy as such agreements reduce overuse, misuse, abuse, and diversion. (Evidence: fair) 7. A) Once medical necessity is established, opioid therapy may be initiated with low doses and short-acting drugs with appropriate monitoring to provide effective relief and avoid side effects. (Evidence: fair for short-term effectiveness, limited for long-term effectiveness) B) Up to 40 mg of morphine equivalent is considered as low dose, 41 to 90 mg of morphine equivalent as a moderate dose, and greater than 91 mg of morphine equivalence as high dose. (Evidence: fair) C) In reference to long-acting opioids, titration must be carried out with caution and overdose and misuse must be avoided. (Evidence: good) 8. A) Methadone is recommended for use in late stages after failure of other opioid therapy and only by clinicians with specific training in the risks and uses. (Evidence: limited) B) Monitoring recommendation for methadone prescription is that an electrocardiogram should be obtained prior to initiation, at 30 days and yearly thereafter. (Evidence: fair) 9. In order to reduce prescription drug abuse and doctor shopping, adherence monitoring by UDT and PMDPs provide evidence that is essential to the identification of those patients who are non-compliant or abusing prescription drugs or illicit drugs. (Evidence: fair) 10. Constipation must be closely monitored and a bowel regimen be initiated as soon as deemed necessary. (Evidence: good) 11. Chronic opioid therapy may be continued, with continuous adherence monitoring, in well-selected populations, in conjunction with or after failure of other modalities of treatments with improvement in physical and functional status and minimal adverse effects. (Evidence: fair). DISCLAIMER: The guidelines are based on the best available evidence and do not constitute inflexible treatment recommendations. Due to the changing body of evidence, this document is not intended to be a "standard of care."

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