ACOEM Guidelines for Chronic Use of Opioids
The overuse of opioid therapy to treat chronic pain conditions is becoming epidemic in the United States. While opioid therapy may be appropriate in carefully selected cases, active monitoring and adverse event anticipation are crucial. As part of its commitment to worker health and safety, the American College of Occupational and Environmental Medicine (ACOEM) is providing these ACOEM Guidelines for the Chronic Use of Opioids free to the medical community. The opioid guidelines were developed by an evidence-based, multidisciplinary expert panel in order to manage injured workers whose pain has not been controlled by more conservative means. These guidelines have been developed from ACOEM’s updated 2008 Chronic Pain chapter. The chapter is included with the 3rd edition of ACOEM’s Occupational Medicine Practice Guidelines.
Opioids are not invasive, have high adverse effects for a drug although tolerance to many of these do develop relatively rapidly, and are low cost when generic formulations are used. Chronic use of brand name medications may be moderate to high cost. While routine use of opioids for treating patients with chronic pain is not recommended, opioids are recommended for select patients in chronic pain settings after other treatment options have been exhausted in a manner consistent with the recommendations in this section. A shared decision-making model has been advocated for treating patients with chronic pain, although there are no quality studies of patient outcomes. There is no quality evidence that one preparation is superior to another for treatment of chronic pain, and no consistent evidence of significant differences in efficacy between short and long acting opioids. Many pain specialists recommend using long-acting or sustained acting time released opioids to achieve a stable blood level and that opioids for chronic pain conditions be used on a regular schedule and not as needed.
There are many treatments that should be considered before opioids. Depending on the exact diagnosis, these treatments may include exercise, topical medications, distractants (e.g., heat), NSAIDs, low-dose heterocyclic anti-depressants, anti-convulsant agents, and self-applied palliative modalities such as transcutaneous electrical nerve stimulation (TENS). Of equal importance is the need to consider use of these interventions, especially involvement in programs of active exercise and functional restoration (especially return to work) in conjunction with opioid use. Many injections and other palliative remedies are often considered justifiable for short-term use as a means of facilitating patient involvement in activities that are specifically designed to promote the increases in endurance, strength and range of motion that would presumably allow them to better tolerate activities that previously exacerbated their pain. Given the widely recognized literature demonstrating the relationship between certain forms of exercise and endorphin release, it is likely that the benefit accrued from aerobic exercise and similar activities most likely extends beyond that which can be explained solely in terms of physiologic changes in endurance, strength or flexibility. To embark upon a trial of opioids without concomitantly adding (or reinstating) other appropriate rehabilitative interventions for a given patient appears no more reasonable than providing other palliative treatments, or injections, in isolation and would run the same risk of fostering dependency on an intervention that provides no functional benefit itself. Indeed, it may well be that the unimpressive (at best) results from even those studies that claim to demonstrate benefit from use of opioids may reflect failure to use these agents as part of an integrated approach to the patient’s care. While some patients may view opioids as an easy treatment approach and (further) avoid treatments more likely to bring long term therapeutic benefit, physician prescription of opioids without a prior thorough comprehensive patient assessment, and in the absence of a well-defined therapeutic plan focused on improving function is strongly not recommended.
Download the Guidelines for Chronic Use of Opioids