Rethinking the role of opioids in the outpatient management of chronic nonmalignant pain

Objective: Opioid analgesics are commonly and increasingly prescribed by physicians for the management of chronic pain. However, strong evidence supports the need for strategies that reduce opioid use. The objective of this review is to outline limitations associated with opioid use and discuss therapeutic techniques that can be adopted to optimize the use of opioids in the management of chronic nonmalignant pain. Scope: Literature searches through MEDLINE and Cochrane databases were used to identify relevant journal articles. The search was limited to articles published from January 1980 to January 2014. Additional references were obtained from articles extracted during the database search. Relevant search terms included opioid, opioid abuse, chronic pain management, written care agreements, urine drug testing, and multimodal therapy. Findings: Opioids exhibit a well established abuse potential and evidence supporting the efficacy of opioids in chronic pain management is limited. In addition, opioid exposure is associated with adverse effects on multiple organ systems. Effective strategies designed to mitigate opioid abuse and diversion and optimize clinical outcomes should be employed. Conclusions: Appropriate patient selection through identification of risk factors, urine drug testing, and access to prescription monitoring programs has been shown to effectively improve care. Structured opioid therapy in a multimodal platform, including use of a low initial dose, prescription of alternative non-opioid analgesics including non-steroidal anti-inflammatory drugs and acetaminophen, as well as development of written care agreements to individualize and guide therapy has also been shown to improve patient outcomes. Implementation of opioid allocation strategies has the potential to encourage appropriate opioid use and improve patient care.