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Manchikanti L, Kaye AM, Knezevic NN, Giordano J, Applewhite MK, Bautista A, Soin A, Blank SK, Sanapati MR, Karri J, Christo PJ, Abd-Elsayed A, Kaye AD, Calodney A, Navani A, Gharibo CG, Harned M, Gupta M, Broachwala M, Sehgal N, Kaufman A, Wargo B, Solanki DR, Hsu ES, Limerick G, Dennis A, Swicegood JR, Slavin K, Snook L, Pasupuleti R, Kosanovic R, Justiz R, Barkin R, Atluri S, Shah S, Pampati V, Helm Ii S, Grami V, Myckowiak V, Galan V, Singh V, Manocha V, Hirsch JA. Comprehensive, Evidence-Based, Consensus Guidelines for Prescription of Opioids for Chronic Non-Cancer Pain from the American Society of Interventional Pain Physicians (ASIPP). Pain Physician 2023; 26:S7-S126. [PMID: 38117465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
BACKGROUND Opioid prescribing in the United States is decreasing, however, the opioid epidemic is continuing at an uncontrollable rate. Available data show a significant number of opioid deaths, primarily associated with illicit fentanyl use. It is interesting to also note that the data show no clear correlation between opioid prescribing (either number of prescriptions or morphine milligram equivalent [MME] per capita), opioid hospitalizations, and deaths. Furthermore, the data suggest that the 2016 guidelines from the Centers for Disease Control and Prevention (CDC) have resulted in notable problems including increased hospitalizations and mental health disorders due to the lack of appropriate opioid prescribing as well as inaptly rapid tapering or weaning processes. Consequently, when examined in light of other policies and complications caused by COVID-19, a fourth wave of the opioid epidemic has been emerging. OBJECTIVES In light of this, we herein seek to provide guidance for the prescription of opioids for the management of chronic non-cancer pain. These clinical practice guidelines are based upon a systematic review of both clinical and epidemiological evidence and have been developed by a panel of multidisciplinary experts assessing the quality of the evidence and the strength of recommendations and offer a clear explanation of logical relationships between various care options and health outcomes. METHODS The methods utilized included the development of objectives and key questions for the various facets of opioid prescribing practice. Also utilized were employment of trustworthy standards, and appropriate disclosures of conflicts of interest(s). The literature pertaining to opioid use, abuse, effectiveness, and adverse consequences was reviewed. The recommendations were developed after the appropriate review of text and questions by a panel of multidisciplinary subject matter experts, who tabulated comments, incorporated changes, and developed focal responses to questions posed. The multidisciplinary panel finalized 20 guideline recommendations for prescription of opioids for chronic non-cancer pain. Summary of the results showed over 90% agreement for the final 20 recommendations with strong consensus. The consensus guidelines included 4 sections specific to opioid therapy with 1) ten recommendations particular to initial steps of opioid therapy; 2) five recommendations for assessment of effectiveness of opioid therapy; 3) three recommendations regarding monitoring adherence and side effects; and 4) two general, final phase recommendations. LIMITATIONS There is a continued paucity of literature of long-term opioid therapy addressing chronic non-cancer pain. Further, significant biases exist in the preparation of guidelines, which has led to highly variable rules and regulations across various states. CONCLUSION These guidelines were developed based upon a comprehensive review of the literature, consensus among expert panelists, and in alignment with patient preferences, and shared decision-making so as to improve the long-term pain relief and function in patients with chronic non-cancer pain. Consequently, it was concluded - and herein recommended - that chronic opioid therapy should be provided in low doses with appropriate adherence monitoring and understanding of adverse events only to those patients with a proven medical necessity, and who exhibit stable improvement in both pain relief and activities of daily function, either independently or in conjunction with other modalities of treatments.
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Affiliation(s)
- Laxmaiah Manchikanti
- Pain Management Centers of America, Paducah, KY and Evansville, IN; LSU Health Science Center, New Orleans, LA
| | - Adam M Kaye
- Department of Pharmacy Practice, Thomas J. Long School of Pharmacy and Health Sciences, University of the Pacific, Stockton, CA
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center and College of Medicine, University of Illinois, Chicago, IL
| | - James Giordano
- Department of Defense Medical Ethics Center, Uniformed Services University of Health Sciences, Bethesda, MD; Departments of Neurology and Biochemistry and Pellegrino Center for Clinical Bioethics, Georgetown University Medical Center, Washington DC
| | - Megan K Applewhite
- Department of Surgery and MacClean Center of Bioethics, University of Chicago, Chicago, IL; Department of Defense Medical Ethics Center, Uniformed Services University of Health Sciences, Bethesda, MD
| | - Alexander Bautista
- Department of Anesthesiology and Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Amol Soin
- Wright State University Boonshoft School of Medicine, Fairborn, OH; Ohio Pain Clinic, Dayton, OH
| | | | | | - Jay Karri
- Department of Anesthesiology and Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Paul J Christo
- Division of Pain Medicine, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Alaa Abd-Elsayed
- UW Health Pain Services and University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Alan D Kaye
- Louisiana State University School of Medicine, Shreveport, LA
| | - Aaron Calodney
- Precision Spine Care, Tyler, TX and Department of Anesthesiology, Louisiana State University, Shreveport, LA, USA
| | - Annu Navani
- Le Reve Regenerative Wellness, Campbell, CA; Stanford University School of Medicine, Stanford, CA; Boomerang Health Care, Walnut Creek, CA, USA
| | - Christopher G Gharibo
- Peri-Operative Care & Pain Medicine and Orthopedics at NYU Grossman School of Medicine, New York, NY, USA
| | - Michael Harned
- Department of Anesthesiology, Perioperative, Critical Care and Pain Medicine, University of Kentucky, Lexington, KY, USA
| | - Mayank Gupta
- Kansas Pain Management and Neuroscience Research Center, LLC, Overland Park, KS; Department of Clinical Education, Kansas City University of Medicine and Biosciences, Kansas City, MO, USA
| | | | - Nalini Sehgal
- Department of Orthopedics and Rehabilitation, UW Health, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Andrew Kaufman
- Departments of Pain Management and Anesthesiology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Bradley Wargo
- Baptist University, Memphis, TN; Shoals Interventional Pain Management, Muscle Shoals, AL, USA
| | - Daneshvari R Solanki
- University of Texas Medical Branch, Galveston, TX; HD Research, First Surgical Hospital, Bellaire, TX, USA
| | - Eric S Hsu
- Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, CA, USA
| | - Gerard Limerick
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Allen Dennis
- Advanced Pain Care and Round Rock Surgery Center, Round Rock, TX, USA
| | | | - Konstantin Slavin
- Department of Neurosurgery, University of Illinois at Chicago, and Neurology Section, Jesse Brown Veterans Administration Medical Center, Chicago, IL, USA
| | - Lee Snook
- Metropolitan Pain Management Consultants, Inc., Sacramento, CA
| | | | - Radomir Kosanovic
- Interventional Pain Management, Baptist Health South Florida, Miami, FL, USA
| | - Rafael Justiz
- Department of Anesthesiology, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | | | | | - Shalini Shah
- Department of Anesthesiology & Perioperative Care, University of California Irvine Health, Orange, CA, USA
| | | | - Standiford Helm Ii
- Division of Pain Medicine, Department of Anesthesiology and Peri-Operative Care, University of California, Irvine, UCI Health Center for Pain and Wellness, Gottschalk Medical Plaza, Irvine, CA, USA
| | - Vahid Grami
- Department of Anesthesiology and Pain Medicine, Geisinger Commonwealth School of Medicine, Danville, PA, USA
| | - Vicki Myckowiak
- Partner with The Health Law Partners, Farmington Hills, MI, USA
| | - Vincent Galan
- Georgia Pain Care & Affiliated Surgery Center; Center for Pain and Spine, Stockbridge, GA, USA
| | - Vijay Singh
- Spine Pain Diagnostics Associates, Niagara, WI
| | - Vivek Manocha
- Department of Surgery, Wright State University School of Medicine, Dayton, OH; Beacon Orthopedics & Sports Medicine, Cincinnati, OH, USA
| | - Joshua A Hirsch
- Massachusetts General Hospital, Harvard Medical School, Boston, MA
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