Objectives. Provide a framework for comprehensive pain evaluation and individualized multimodal treatment. Improve quality of life and function in patients experiencing pain, while reducing the morbidity and mortality associated with pain treatments, particularly opioid analgesics.

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Massage therapy. Consider massage therapy as part of a multimodal treatment plan. Massage therapy is manual manipulation of muscles and connective tissue to enhance physical rehabilitation and improve relaxation.

When the benefits of adding an opioid to other therapy outweigh the risks, select the initial drug and dose based on the:

This guideline is intended to support clinicians in evaluating and managing patients with pain and in navigating the complex issues involved with the use of opioids for pain management.

Marijuana. Evidence regarding benefits and harms is currently insufficient to recommend using “medical” marijuana for chronic pain. Some data support cannabidiol (CBD) alone as being relatively safe.

A logical rationale for an intervention does not ensure the patient’s acceptance and participation in it. A patient’s acceptance of therapy is influenced by several complex factors, including characteristics of illness and identity.

Assess potential misuse of opioids. Use established criteria to evaluate misuse of opioids by chronic pain patients receiving long-term opioid therapy.101 Meeting 3 or more of the following criteria is defined as misuse.

Special safety hazard and unique advantages. Methadone is unique among opioids, with both increased safety concerns and advantages in long-term therapy. The safe use of methadone requires knowledge of its particular pharmacologic properties. Methadone’s duration of adverse effects far exceeds its analgesic half-life, making it dangerous when combined inappropriately with other controlled substances.

All patients being discharged with opioid medications should receive counseling on the use of prescription opioids.

Discontinue all ineffective medications to avoid polypharmacy, minimize toxicity, and limit unrealistic beliefs about the benefit of medications.

A full discussion of the diagnosis and management of opioid use disorder is beyond the scope of this guideline. However, monitor patients for signs and symptoms of this Shop Now disorder.

Medicolegal risk. A 2017 review of malpractice claims involving the use of opioids for chronic pain found that a variety of patient and clinician factors contribute to poor outcomes and litigation. Medical comorbidities such as obstructive sleep apnea and cardiopulmonary disease, when combined with a long-acting opioid prescription, was identified as a particularly dangerous combination.