American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I—evidence assessment

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, 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
Pain Physician 2012, 15 (3 Suppl): S1-65

BACKGROUND: Opioid abuse has continued to increase at an alarming rate since the 1990 s. As documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration, available evidence suggests a wide variance in chronic opioid therapy of 90 days or longer in chronic non-cancer pain. Part 1 describes evidence assessment.

OBJECTIVES: The objectives of opioid guidelines as issued by the American Society of Interventional Pain Physicians (ASIPP) are to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to produce consistency in the application of an opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of abuse and drug diversion. The focus of these guidelines is to curtail the abuse of opioids without jeopardizing non-cancer pain management with opioids.

RESULTS: 1) There is good evidence that non-medical use of opioids is extensive; one-third of chronic pain patients may not use prescribed opioids as prescribed or may abuse them, and illicit drug use is significantly higher in these patients. 2) There is good evidence that opioid prescriptions are increasing rapidly, as the majority of prescriptions are from non-pain physicians, many patients are on long-acting opioids, and many patients are provided with combinations of long-acting and short-acting opioids. 3) There is good evidence that the increased supply of opioids, use of high dose opioids, doctor shoppers, and patients with multiple comorbid factors contribute to the majority of the fatalities. 4) There is fair evidence that long-acting opioids and a combination of long-acting and short-acting opioids contribute to increasing fatalities and that even low-doses of 40 mg or 50 mg of daily morphine equivalent doses may be responsible for emergency room admissions with overdoses and deaths. 5) There is good evidence that approximately 60% of fatalities originate from opioids prescribed within the guidelines, with approximately 40% of fatalities occurring in 10% of drug abusers. 6) The short-term effectiveness of opioids is fair, whereas the long-term effectiveness of opioids is limited due to a lack of long-term (> 3 months) high quality studies, with fair evidence with no significant difference between long-acting and short-acting opioids. 7) Among the individual drugs, most opioids have fair evidence for short-term and limited evidence for long-term due to a lack of quality studies. 8) The evidence for the effectiveness and safety of chronic opioid therapy in the elderly for chronic non-cancer pain is fair for short-term and limited for long-term due to lack of high quality studies; limited in children and adolescents and patients with comorbid psychological disorders due to lack of quality studies; and the evidence is poor in pregnant women. 9) There is limited evidence for reliability and accuracy of screening tests for opioid abuse due to lack of high quality studies. 10) There is fair evidence to support the identification of patients who are non-compliant or abusing prescription drugs or illicit drugs through urine drug testing and prescription drug monitoring programs, both of which can reduce prescription drug abuse or doctor shopping.

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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