Opioid Prescribing for Chronic Pain

Care for People 15 Years of Age and Older

Click below to see a list of brief quality statements and scroll down for more information.

Quality Statements in Brief

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment
People with chronic pain receive a comprehensive assessment, including consideration of their functional status and social determinants of health.

Quality Statement 2: Setting Goals for Pain Management and Function
People with chronic pain set goals for pain management and functional improvement in partnership with their health care professionals. These goals are evaluated regularly.

Quality Statement 3: First-Line Treatment With Non-opioid Therapies
People with chronic pain receive an individualized and multidisciplinary approach to their care. They are offered non-opioid pharmacotherapy and nonpharmacological therapies as first-line treatment.

Quality Statement 4: Shared Decision-Making and Information on the Potential Benefits and Harms of Opioids for Chronic Pain
People with chronic pain, and their families and caregivers receive information about the potential benefits and harms of opioid therapy for chronic pain at the time of both prescribing and dispensing so that they can participate in shared decision-making.

Quality Statement 5: Initiating a Trial of Opioids for Chronic Pain
People with chronic pain begin a trial of opioid therapy only after other multimodal therapies have been tried without adequate improvement in pain and function, and they either have no contraindications to opioid therapy or have discussed any relative contraindications with their health care professional.

If opioids are initiated, the trial starts at the lowest effective dose, preferably below 50 mg morphine equivalents per day. Titrating over time to a dose of less than 90 mg morphine equivalents per day may be warranted in selected cases in which people are willing to accept a higher risk of harm for an improved pain relief.

Quality Statement 6: Co-prescribing Opioids and Benzodiazepines
People with chronic pain are not prescribed opioids and benzodiazepines at the same time whenever possible.

Quality Statement 7: Opioid Use Disorder
People prescribed opioids for chronic pain who are subsequently diagnosed with opioid use disorder have access to opioid agonist therapy.

Quality Statement 8: Prescription Monitoring Systems
Health care professionals who prescribe or dispense opioids have access to a real-time prescription monitoring system at the point of care. Prescription history is checked when opioids are prescribed and dispensed and every 3 to 6 months during long-term use, or more frequently if there are concerns regarding duplicate prescriptions, potentially harmful medication interactions, or diversion.

Quality Statement 9: Tapering and Discontinuation
All people with chronic pain on long-term opioid therapy, especially those taking 90 mg morphine equivalents or more per day, are periodically offered a trial of tapering to a lower dose or tapering to discontinuation.

Quality Statement 10: Health Care Professional Education
Health care professionals have the knowledge and skills to appropriately assess and treat chronic pain using a multidisciplinary, multimodal approach; appropriately prescribe, monitor, taper, and discontinue opioids; and recognize and treat opioid use disorder.

Resources Quality Statements Advisory Committee About

Shared Decision-Making and Information on the Potential Benefits and Harms of Opioids for Chronic Pain

People with chronic pain, and their families and caregivers receive information about the potential benefits and harms of opioid therapy for chronic pain at the time of both prescribing and dispensing so that they can participate in shared decision-making.

Background

Health care professionals should engage people with chronic pain in shared decision-making, including a consideration of the person’s management goals, preferences, and values, to determine the best treatment strategy for each person. The potential harms associated with opioids prescribed for chronic pain include constipation, nausea and vomiting, cognitive changes, hypogonadism, physical dependence, opioid use disorder, nonfatal unintentional overdose, and death. If a person with chronic pain is considering opioids, health care professionals should provide information on the following:

The potential benefits and harms of opioid therapy and alternative treatments
The responsibilities of the person with chronic pain, the prescriber, and the pharmacist
A monitoring schedule to reassess progress toward goals for pain management and function every 3 months

Clinicians should also recommend laxatives to people being prescribed opioids for chronic pain.

The use of screening tools for opioid use disorder and other substance use disorders is suggested; however, clinical judgment is of paramount importance, as no screening tool is sufficiently accurate to be used as the sole method of identifying substance use disorders. Clinicians should discuss the symptoms of opioid use disorder and overdose with people considering opioids for chronic pain. Clinicians may consider offering co-prescribed naloxone when prescribing opioids for chronic pain, although evidence on the benefits of this practice has not yet been established.

What This Quality Statement Means

For Patients

Your health care professional should explain the potential benefits and harms of opioid medications for chronic pain so that you can make decisions about your care together. If you have family involved in your care, they should also receive this information. Potential harms of opioid medications include becoming dependent on the medication, uncomfortable withdrawal symptoms when you stop taking the medication, addiction, and overdose.

For Clinicians

Provide people with chronic pain, and their families and caregivers as appropriate, with information on the potential benefits and harms of opioid therapy in an accessible format before initiating a trial of opioids.

For Health Services

Ensure that evidence-based, unbiased information is available in a variety of formats for people with chronic pain. Provide an environment that allows clinicians to have conversations about various therapy options with people with chronic pain and their families and caregivers.

Quality Indicators

Process Indicators

Percentage of people with chronic pain prescribed an opioid who received information about the benefits and harms of opioid therapy prior to being prescribed opioid therapy

Denominator: total number of people with chronic pain who were prescribed an opioid
Numerator: number of people in the denominator with documentation of receiving information about the benefits and harms of opioid therapy prior to being prescribed opioid therapy
Data source: local data collection

Percentage of people with chronic pain prescribed an opioid who received information about the benefits and harms of opioid therapy prior to being dispensed an opioid

Denominator: total number of people with chronic pain who were dispensed an opioid
Numerator: number of people in the denominator with documentation of receiving information about the benefits and harms of opioid therapy prior to being dispensed an opioid
Data source: local data collection

Percentage of people with chronic pain prescribed an opioid who reported that their health care professional always or often involves them as much as they want in decisions about their care and treatment for pain

Denominator: total number of people with chronic pain who were prescribed an opioid
Numerator: number of people in the denominator who reported that their health care professional always or often involves them as much as they want in decisions about their care and treatment
Data source: local data collection
Sample survey question: “When you see your care provider or someone else in their office, how often do they involve you as much as you want in decisions about your care and treatment?” (Response options: Always, Often, Sometimes, Rarely, Never, It depends on who I see and/or what I am there for, Not using or on any treatments/Not applicable, Don’t know, Refused)

Definitions Used Within This Quality Statement

Information

Information should be provided to people with chronic pain during in-person visits verbally and via printed or multimedia formats. This information should include, at a minimum, content related to the following:

The potential benefits and harms of opioid therapy for chronic pain
Alternative non-opioid therapies for chronic pain, their benefits and harms, and their costs
The types of health care professionals who may be involved in multimodal, multidisciplinary therapy for chronic pain
The risks and symptoms of physical dependence and withdrawal
Factors that increase the risk of opioid use disorder, nonfatal overdose, and death
The safe storage and disposal of opioids to prevent diversion and reduce safety risks in the community
How to recognize and respond to an opioid overdose

Shared decision-making

Shared decision-making is a collaborative process that allows people with chronic pain, their families and caregivers, and health care professionals to make decisions together. The health care professional is responsible for the following:

Inviting the person with chronic pain to participate in the decision-making process
Presenting pain management options
Providing information on the potential benefits and harms of each pain management option
Helping people evaluate pain management options based on their values and preferences
Facilitating deliberation and decision-making
Helping implement decisions
Offering and incorporating decision-making tools such as decision aids

Evidence to Improve Care