AAPM 2009: New Guidelines on Chronic Opioid Therapy Presented

Allison Gandey

February 02, 2009

February 2, 2009 (Honolulu, Hawaii) — New guidelines on chronic opioid therapy were presented here at the American Academy of Pain Medicine 25th Annual Meeting. The 22 panel members developing the guidelines are from the academy and the American Pain Society. Their work is published in the February issue of the Journal of Pain.

Dr. Perry Fine unveiled the committee findings.

"This is the first time these issues have been codified in this way," presenter Perry Fine, MD, from the University of Utah School of Medicine, in Salt Lake City, told Medscape Neurology & Neurosurgery. "Of the many issues we tried to confront, key points include the importance of a therapeutic trial, justification for long-term therapy, and continuous reevaluation."

"This was a big concerted effort, and the committee should be commended on an outstanding job," session moderator Ajay Wasan, MD, from Harvard Medical School and Brigham and Women's Hospital, in Boston, Massachusetts, said during an interview.

Dr. Fine said the committee was concerned about patients with chronic debilitating pain who are not being adequately treated and are not sufficiently evaluated or considered potential beneficiaries of opioid pharmacotherapy. Conversely, members also wanted to address the problem of patients receiving opioids who are not good candidates.

"The best outcome of these new guidelines is that we match the right patient with the right drug and encourage optimal evaluation over time," Dr. Fine said.

More Study Needed

But the guidelines, he noted, are not without limitations. "This process unearthed how much we don't know that we really need to know. I think this has created almost a research agenda that we can now go forward with."

Dr. Wasan said he agreed but pointed to the complexities and complications of quantitatively studying many of the issues pertaining to pain management and opioid therapy. "In some cases, we are going to have to continue relying on qualitative evidence. It is unfortunate, but we don't have a better approach."

During his talk, Dr. Fine said that clinicians cannot wait for high-quality evidence to guide what they are doing every day in practice. The committee weighed evidence and applied expert consensus to offer the best clinical guidance available at this time.

Penney Cowan, founder and executive director of the American Chronic Pain Association, said she is confident the new guidelines will help inform clinical practice. "Knowing this committee, I believe that what it has come up with will be excellent. What will be important next is how people interpret these guidelines."

The new guidelines offer detail on patient selection and risk stratification. They encourage informed consent and the development of an opioid management plan, which clinicians may consider putting in writing in collaboration with patients.

The guidelines also outline initiation and titration strategies. According to the panel, prescribers should regard the initiation of opioids as a therapeutic trial to determine whether ongoing therapy is appropriate.

The Challenge of Methadone

The committee also highlighted methadone in the treatment guidelines. "Methadone is characterized by complicated and variable pharmacokinetics and pharmacodynamics and should be initiated and titrated cautiously by clinicians familiar with its use and risks," the panel writes.

The guidelines also stress frequent monitoring and reevaluation. Other key points include:

  • High-risk patients.

  • Dose escalation and high-dose therapy.

  • Adverse effects.

  • Use of nonopioid therapies.

  • Driving and work safety.

  • Breakthrough pain.

  • Opioids and pregnancy.

"Until a pharmacotherapy class as efficacious and versatile as the opioids emerge, clinicians need to learn how to select patients for opioid therapy when indicated and manage them as safely and effectively as possible," Dr. Fine said at the meeting.

"We shouldn't be pro-opioid or anti-opioid but prohealth and make our treatment decisions with patients in that context."

Ms. Cowan said she agreed and added, "It's important that clinicians understand the complexity of pain management and that choosing the right medication is just 1 aspect. I compare the person with pain to a car with 4 flat tires. Choosing an opioid may put air in 1 tire, but there are still 3 more flats, and we have to address those as well."

Dr. Fine added, "Everyone has guidelines and they mostly sit on a shelf. These guidelines shouldn't."

Dr. Fine reports he is on advisory boards for Alpharma Pharmaceuticals, Endo, Eli Lilly, Ortho-McNeil-Janssen, Wyeth, and GlaxoSmithKline and is a consultant for Cephalon.

American Academy of Pain Medicine 25th Annual Meeting. Presented January 28, 2009.

J Pain 2009;10;113-130.

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