gms | German Medical Science

Background: Opioid prescription rates, and related emergency visits, fractures, adverse effects and mortality rates have risen sharply in the US over the last 10 years. Many clinicians are now seeking guidance about the appropriate use and risk to benefit balance of opioid treatment for chronic non-cancer pain (CNCP).

Objective: To assess and compare systematic reviews and guideline recommendations on the relative effectiveness, risks and management of opioids for chronic pain.

Methods: We searched major data bases for population studies, systematic reviews and guidelines on opioid use for CNCP. We identified four systematic reviews meeting inclusion criteria and six comprehensive guidelines which included systematic reviews. We compared methodologies, evidence syntheses and guidelines recommendations. We then identified areas for which guidance was insufficient.

Results: SRs revealed that efficacy studies with placebo comparisons lasted ≤3 months and produced low levels of pain relief. Retrospective cohort studies document high levels of psychiatric comorbidities and dose- and comorbidity-related adverse effects of opioids. Guidelines focused on containment of substance misuse but were not helpful regarding specific indications and use with psychiatric comorbidity.

Discussion: The efficacy and safety of opioids for chronic pain have not been substantiated in available studies. There are significant personal and public health problems associated with the increasing use of chronic opioids. Guidelines do not provide clear guidance for indications, patients with comorbidities, and risks of adverse effects.

Implications for guideline developers/users: More consistent, evidence-based prescribing patterns may improve effectiveness and patient safety. Research designs should be improved.