Pain Physician. 2006;9:1-40, ISSN 1533-3159 Opioid Guidelines Opioid Guidelines in the Management of Chronic Non-Cancer Pain Andrea M. Trescot, MD, Mark V. Boswell, MD, Sairam L. Atluri, MD, Hans C. Hansen, MD, Timothy R. Deer, MD, Salahadin Abdi, MD, Joseph F. Jasper, MD, Vijay Singh, MD, Arthur E. Jordan, MD, Benjamin W. Johnson, MD, Roger S. Cicala, MD, Elmer E. Dunbar, MD, Standiford Helm II, MD, Kenneth G. Varley, MD, P.K. Suchdev, MD, John R. Swicegood, MD, Aaron K. Calodney, MD, Bentley A. Ogoke, MD, W. Stephen Minore, MD, and Laxmaiah Manchikanti, MD Background: Opioid abuse has in- creased at an alarming rate. However, avail- able evidence suggests a wide variance in the use of opioids, as documented by differ- ent medical specialties, medical boards, ad- vocacy groups, and the Drug Enforcement Administration (DEA). Objectives: The objective of these opi- oid guidelines by the American Society of In- terventional Pain Physicians (ASIPP) is to pro- vide guidance for the use of opioids for the treatment of chronic non-cancer pain, to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of drug diversion. Design: A policy committee evaluated a systematic review of the available literature regarding opioid use in managing chronic non-cancer pain. This resulted in the formu- lation of the essentials of guidelines, a series of potential evidence linkages representing conclusions, followed by statements regard- ing relationships between clinical interven- tions and outcomes. Methods: Consistent with the Agency for Healthcare Research and Quality (AHRQ) hierarchical and comprehensive standards, the elements of the guideline preparation process included literature searches, litera- ture synthesis, systematic review, consen- sus evaluation, open forum presentations, formal endorsement by the Board of Direc- tors of the American Society of Intervention- al Pain Physicians (ASIPP), and blinded peer review. Evidence was designated based on scientific merit as Level I (conclusive), Level II (strong), Level III (moderate), Level IV (lim- ited), or Level V (indeterminate). Results: After an extensive review and analysis of the literature, the authors uti- lized two systematic reviews, two narrative re- views, 32 studies included in prior systematic reviews, and 10 additional studies in the syn- thesis of evidence. The evidence was limited. Conclusion: These guidelines evaluat- ed the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientific evidence and do not constitute in- flexible treatment recommendations. Be- cause of the changing body of evidence, this document is not intended to be a “standard of care.” Key Words: Chronic pain, persistent pain, controlled substances, substance abuse, dependency, prescription account- ability, opioids, prescription monitoring, di- version, guidelines From: American Society of Interventional Pain Phy- sicians, Paducah, KY Address Correspondence: Laxmaiah Manchikanti, MD Chief Executive Officer, ASIPP 81 Lakeview Drive, Paducah, KY 42001 E-mail: drm@apex.net Disclaimer: There was no external funding in the preparation of this manuscript. Conflict of Interest: None Funding: Internal funding was provided by the American Society of Interventional Pain Physicians and was limited to travel and lodging expenses for the authors. CONTENTS 1.0 INTRODUCTION 1.1 Purpose 1.2 Rationale and Importance 1.3 Objectives and Benefits 1.4 Population and Preferences 1.5 Implementation and Review 1.6 Application 1.7 Focus 1.8 Methodology 2.0 CHRONIC PAIN 2.1 Definitions 2.2 Prevalence 2.3 Chronicity 2.4 Health and Economic Impact 3.0 OPIOIDS IN CHRONIC PAIN 3.1 General Considerations 3.2 Response to Undertreatment 3.3 Opioid Use in Chronic Pain 3.4 Non-Medical Use of Prescription Drugs 3.4.1 Center on Addiction and Substance Abuse (CASA) Findings 3.4.2 Physician Survey Highlights 3.4.3 Pharmacist Survey Highlights 3.4.4 Substance Abuse and Mental Health Services Administration (SAMHSA) Survey 3.4.5 Drug Abuse Warning Network (DAWN) Reports 3.5 Substance Abuse in Chronic Pain 3.6 Economic Impact 3.7 Drug Diversion 3.8 Controlling Diversion and Abuse 3.8.1 Drug Enforcement Administration (DEA) 3.8.2 State Laws and Regulations 3.8.3 Prescription Drug Monitoring Programs 4.0 PHARMACOLOGICAL CONSIDERATIONS 4.1 Opioid Pharmacology 4.1.1 Opioid Receptors 4.1.2 Opioid Categories 4.1.3 Opioid Metabolism 4.2 Pharmacology of Specific Opioids 4.2.1 Morphine 4.2.2 Codeine 4.2.3 Dihydrocodeine 4.2.4 Hydrocodone 4.2.5 Oxycodone 4.2.6 Hydromorphone 4.2.7 Methadone 4.2.8 Fentanyl 4.2.9 Meperidine 4.2.10 Pentazocine 4.2.11 Propoxyphene 4.2.12 Tramadol