Pain Core Curriculum Module 3: Evidence for and Management of Opioids for Chronic Pain-Presentation

Video Transcription

Video Summary

This module by Roger Chow from Oregon Health and Science University reviews opioid pharmacology and evidence-based management of opioids for chronic non-cancer pain. Opioids show modest short-term benefits over placebo or non-opioid therapies in pain reduction and function, with an average pain improvement of less than 1 point on a 0-10 scale. Their use carries significant risks, including side effects, opioid use disorder, and overdose, with higher doses correlating with increased risk. Given limited long-term efficacy and safety concerns, opioids should not be first-line therapy but may be considered in select patients after non-opioid options fail. Initiation should start low, with immediate-release opioids preferred, and doses increased slowly with close monitoring. Methadone and fentanyl require special caution due to complex pharmacokinetics and overdose risk. Risk mitigation includes patient selection, avoiding benzodiazepines, urine drug testing, prescribing naloxone, and frequent follow-up. Opioid rotation may improve outcomes but requires expertise. Discontinuation or tapering should be slow and individualized, addressing withdrawal symptoms and continuing non-opioid pain management. The presentation emphasizes balancing modest benefits against potential harms, advocating judicious opioid use, thorough risk assessment, and use of multidisciplinary support, including addiction treatment resources when needed. The illustrated case showed successful slow tapering from very high opioid doses without worsening pain or function, highlighting the feasibility of careful opioid reduction.

Keywords

opioid pharmacology

chronic non-cancer pain

opioid risks

opioid use disorder

opioid tapering

risk mitigation

opioid rotation

multidisciplinary pain management