Opioids and Chronic Pain

 

Is Daily Opioid Treatment Effective?

Many pain experts question the use of opioid (narcotic) medications taken consumed on a daily basis for the management of chronic pain. The Department of Health and Human Services/ Agency for Healthcare Research and Quality report, The Effectiveness and Risks of Long-term Opioid Treatment of Chronic Pain (2104) concluded that "Evidence on long-term opioid therapy for chronic pain is very limited, but suggests an increased risk of serious harms that appears to be dose-dependent.” 


What is High Dose Treatment?


It depends on the guideline, but the most recent guidelines consider morphine 50-120 mg/day to be high risk. Other opioids are routinely converted to "morphine equivalency" and there are many online calculators. For the most commonly prescribed opioid, morphine 50-120mg/d is about equal to hydrocodone 50-120 mg/day or oxycodone 35-90mg/day.


American College of Occupational and Environmental Medicine (2014): "The maximum daily oral dose recommended for subacute or chronic pain patients based on risk of overdose/death is 50mg morphine equivalent dose (MED). In rare cases with documented functional improvements occurring with use above 50 mg MED, subsequent doses up to 100 mg may be considered, however, risks of death are much greater and more intensive monitoring is then also recommended."


Washington State Agency Medical Directors’ Group (2010) “In general, the total daily dose of opioid should not exceed 120 mg oral MED. Risks substantially increase at doses at or above 100mg, so early attention to this benchmark dose is worthwhile”.


Arizona Statute §23-1062.02 relating to payment of Workers’ Compensation requires physicians to provide written clinical justification when prescribing opioids in amounts greater than 120 mg of morphine equivalent per day.