In general, long-term opioids should not be a key strategy in the management of a chronic pain patient. When starting or continuing opioid therapy, it is necessary to consider the indications and contraindications for opioid use.

Patient selection: chronic pain patient


Indications - all of the following:

(1) pain expected to respond to opioids

(2) there is no better modality for treating the pain

(3) benefits outweigh risks


Contraindications - any of the following:

(1) likelihood of severe adverse reactions

(2) failure to achieve goals despite optimized dosing

(3) reason to discontinue


When starting opioids, start with a short-acting opioid not exceeding 20 MMED.


Once therapy is started, it may be necessary to titrate the dose up or down. Doses exceeding 50 MMED indicates failure of opioid therapy to control pain.


If problems arise, then the options are:

(1) discontinue opioids, using non-opioid interventions

(1) consider switching to buprenorphine therapy.

(2) refer to a pain specialist and/or addiction specialist should be considered.

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