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long-term opiate therapy

Indications: - cancer pain - little evidence to support use of long-term opiate therapy for non-cancer chronic pain, but is done anyway [1] Complications: - see opioid agonist - constipation Management: - surveillance with a prescription monitoring program [1] - frequent & regularly schedule office visits* - baseline & periodic urine drug testing to assess adherence - no recommendation for urine drug testing every visit [1] - constipation - stimulant laxative (senna) all patients [1] - docusate as needed - naloxegol (Movantik), naldemedine (Symproic) - tolerance does NOT develop to constipating effects - reduction or cessation of long-term opiate therapy may improve pain, function, & quality of life [12] * ref [1] gives examples of what would not be an adequate follow-up schedule (initially, every 6 months is inadequate as is an as needed schedule after 3 monthly visits), but does not give an example of what would be (monthy, quarterly?)

Related

chronic pain opioid receptor agonist (narcotic)

General

long-term pharmacologic therapy

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 17, 18. American College of Physicians, Philadelphia 2015, 2018.
  2. Prescriber's Letter 21(4): 2014 Treatment Agreements for Chronic Pain Patients. Detail-Document#: 300424 (subscription needed) http://www.prescribersletter.com
  3. Franklin GM et al Opioids for chronic noncancer pain. Neurology September 30, 2014 vol. 83 no. 14 1277-1284 PMID: 25267983 http://www.neurology.org/content/83/14/1277
  4. Reuben DB et al National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Ann Intern Med. Published online 13 January 2015 PMID: 25581341 http://annals.org/article.aspx?articleid=2089371 - Chou R, Turner JA, Devine EB et al The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. Published online 13 January 2015 PMID: 25581257 http://annals.org/article.aspx?articleid=2089370
  5. Bair MJ et al. Evaluation of stepped care for chronic pain (ESCAPE) in veterans of the Iraq and Afghanistan conflicts: A randomized clinical trial. JAMA Intern Med 2015 Mar 9 PMID: 25751701 http://archinte.jamanetwork.com/article.aspx?articleid=2174941
  6. Makris UE, Abrams RC, Gurland B, Reid MC. Management of persistent pain in the older patient: a clinical review. JAMA. 2014 Aug 27;312(8):825-36. PMID: 25157726
  7. Centers for Disease Control and Prevention (CDC) Proposed 2016 Guideline for Prescribing Opioids for Chronic Pain. Federal Register. Dec 14, 2015 https://www.federalregister.gov/articles/2015/12/14/2015-31375/proposed-2016-guideline-for-prescribing-opioids-for-chronic-pain - Draft CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016 http://www.regulations.gov/#!documentDetail;D=CDC-2015-0112-0002
  8. Dowell D, Haegerich TM, Chou R CDC Guideline for Prescribing Opioids for Chronic Pain. United States, 2016 http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1er.htm - Olsen Y The CDC Guideline on Opioid PrescribingRising to the Challenge. JAMA. Published online March 15, 2016 PMID: 26978227 http://jama.jamanetwork.com/article.aspx?articleid=2503503 - Lee TH Zero Pain Is Not the Goal. JAMA. Published online March 15, 2016 PMID: 26978460 http://jama.jamanetwork.com/article.aspx?articleid=2503504
  9. Volkow ND, McLellan AT Opioid Abuse in Chronic Pain - Misconceptions and Mitigation Strategies. N Engl J Med 2016; 374:1253-1263March 31, 2016 PMID: 27028915 http://www.nejm.org/doi/full/10.1056/NEJMra1507771
  10. Manchikanti L, Abdi S, Atluri S et al American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I--evidence assessment. Pain Physician. 2012 Jul;15(3 Suppl):S1-65. PMID: 22786448 Free Article - Manchikanti L, Abdi S, Atluri S et al American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2--guidance. Pain Physician. 2012 Jul;15(3 Suppl):S67-116. PMID: 22786449 Free Article
  11. Nuckols TK, Anderson L, Popescu I et al Opioid prescribing: a systematic review and critical appraisal of guidelines for chronic pain. Ann Intern Med. 2014 Jan 7;160(1):38-47. Review. PMID: 24217469
  12. Frank JW, Lovejoy TI, Becker WC et al Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med. 2017. July 18. PMID: 28715848 http://annals.org/aim/article/2643842/patient-outcomes-dose-reduction-discontinuation-long-term-opioid-therapy-systematic - Dowell D, Haegerich TM Changing the Conversation About Opioid Tapering. Ann Intern Med. 2017. July 18. PMID: 28715842 http://annals.org/aim/article/2643843/changing-conversation-about-opioid-tapering
  13. Liebschutz JM, Xuan Z, Shanahan CW et al. Improving adherence to long-term opioid therapy guidelines to reduce opioid misuse in primary care: A cluster-randomized clinical trial. JAMA Intern Med 2017 Jul 17 PMID: 28715535