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Prescribing drugs of dependence in general practice

Part C2 - The role of opioids in pain management - Chapter 7

Patient selection for opioid therapy

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Last revised: 02 Jun 2020

GPs should be aware that certain patient groups have increased risks of harm in association with opioid use. As part of a patient selection and risk stratification approach, the following patient group attributes should be considered.

Most drugs that are used for pain management cross the placenta. The Australian Drug Evaluation Committee (ADEC) classifies drugs according to fetal risk and notes that there are particular times of concern during pregnancy: weeks 4–10 (organogenesis), and just before delivery. Opioid analgesics taken just before delivery may cause respiratory depression in the newborn, and withdrawal effects may occur in neonates of dependent mothers.

It is always better to avoid drugs during pregnancy. If medication for constant pain relief is required during pregnancy, consultation should occur with a specialist obstetrician or pain physician.

In practice

Prescribers should avoid initiating opioid therapy in pregnant women whenever possible. It is accepted that prescription of ORT for pregnant women with opioid related substance misuse is a harm minimisation strategy.

For pregnant women already on opioids, opioid therapy should be tapered to the lowest effective dose slowly enough to avoid withdrawal symptoms and then discontinued if possible.78 GPs should access appropriate expertise if considering tapering opioids because of possible risk to the woman and to the fetus if withdrawal occurs.8

During breastfeeding, occasional doses of opioids are considered safe, but codeine should be avoided. Use repeated doses with caution, especially if the infant is premature or under four weeks of age. The infant should be monitored for sedation and other adverse effects.157

Patients on workers’ compensation are at risk of being prescribed high-dose opioids, because of higher levels of psychological distress, poorer surgical outcomes and protracted involvement in legal proceedings.406

It is well recognised that patients who are psychologically distressed after a work injury have poorer outcomes.234,407 Therefore, as soon as distress is recognised (even at the first consultation), the patient should be referred to an appropriate health professional (commonly a psychologist) and therapeutic steps undertaken to minimise opioid use.

Evidence also shows that, where possible and appropriate, returning to work has substantial benefits in improving patient morbidity and decreasing mortality.408 When assessing the capacity of the patient to return to work, patient self-assessment of ability is usually reliable, if it matches clinician impression. Activity is not limited to work but includes the usual activities that the patient undertakes in sport, recreation and at home.

For low back pain, patients are most at risk of developing chronic pain syndrome in the period between 8–12 weeks following the date of pain onset.409,410 However, recovery rates are not improved by commencing a new activity program in the first 4–6 weeks after injury.82,411

In practice

Clinicians and patients should be aware of the risks involved with workers’ compensation patients, and focus rehabilitation on increasing function, non-pharmacological approaches and keeping opioid analgesia to a minimum.

The most important treatment modality for musculoskeletal injuries is returning to as much of the patient’s usual activity as soon as possible. For cases of increased complexity multidisciplinary involvement is beneficial, including teamwork with specialists and a physiotherapist with pain management experience.

Opioids can interfere with a complex task such as driving due to sedation; diminished reaction times, reflexes and coordination; reduced peripheral vision due to the persistent miotic effects;412 and decreased ability to concentrate.413

There is little direct evidence that opioid analgesics (eg hydromorphone, morphine or oxycodone) have direct adverse effects on driving behaviour.414 The risk of accidents appears at increased risk in the first weeks of starting opioid therapy or after increasing the dose.413,415 This may be dose dependent.416

There does not appear to be evidence that any one opioid has less impact than another.417 However, stable doses of sustained-release opioids do not appear to impair driving activity.415,418,419

According to Austroads, a person is not fit to hold an unconditional licence if they have an alcohol disorder or other SUD (eg substance dependence, heavy frequent alcohol or other substance use) that is likely to impair safe driving.414,420

The state or territory driver licensing authority may consider a conditional licence. This is subject to periodic review, taking into account the nature of the driving task and information provided by the treating doctor as to whether the following criteria are met:420

  • The person is involved in a treatment program and has been in remission for at least three months.
  • There is an absence of cognitive impairments relevant to driving.
  • There is absence of end-organ effects that impact on driving.

In practice

Each patient should be considered individually and it is ultimately the prescriber’s judgement that determines opioid prescription.421–424 Where there are concerns about a patient’s ability to drive (eg high doses of opioids or opioids plus other sedative medication), a formal driving assessment may be considered.

When starting opioid therapy, patients should be advised that they are likely to be impaired and should not drive until a stable regime has been obtained for at least two weeks.

There is moderate, generally consistent evidence that driving performance of patients on long-term opioids for chronic pain may not be negatively affected by their medication.413,425 Driving at night may be a problem due to the persistent miotic effects of opioid drugs reducing peripheral vision.412

Sleep-disordered breathing describes a spectrum of disorders, including obstructive sleep apnoea (OSA). One in 15 adults has moderate or more severe OSA, experiencing partial or complete cessation of breathing many times during sleep, and around 80% of those who could benefit from treatment remain undiagnosed.426

Compared to people without OSA, people with OSA are at higher risk of increased sensitivity to opioid analgesia and decreased sensitivity to pain.427 Administration of opioids may also exacerbate OSA.428,429

Experts in this area recommend non-opioid analgesics, and other pain management techniques should be used as either an alternative to opioids or to help limit the amount of opioid required.430–432

In practice

If opioids are prescribed for patients with mild sleep-disordered breathing, careful monitoring and cautious dose titration should be used. Prescribing opioids to patients with moderate or severe sleep-disordered breathing should be avoided whenever possible to minimise risks for opioid overdose.8,433

The use of opioids in patients with severe untreated sleep apnoea is not recommended.101

As the population ages the challenge of safe and appropriate pain management increases. Management challenges include age-related changes in physiology, increased risk of falls,434,435 pharmacodynamics and pharmacokinetics, higher prevalence of comorbidities and concurrent medications, altered responses to pain, and difficulties with assessment of pain severity and response to treatment, including problems related to cognitive impairment.

Consider the use of non-drug strategies such as movement, exercise, physiotherapy and psychological therapies as alternatives to, or in combination with, medication.436 Where opioids are used, consider risk assessment for falls and interventions to mitigate common risks of opioid therapy such as constipation. Also, monitor older patients for the presence of cognitive impairment.8,436

Despite the higher incidence of side effects with drug therapy in older people, analgesics may still be safely and effectively used if tailored for the individual patient and comorbidity and other medications are considered.436 However, analgesics should be:436

  • initiated one at a time using a low dose
  • monitored regularly and adjusted as needed to improve efficacy and limit adverse events
  • titrated slowly according to response
  • used in combination where synergistic effects provide improved pain relief with fewer side effects than higher doses of a single drug.

When prescribing opioids to older adults, it is important to provide education about risky medication-related behaviours such as obtaining controlled medications from multiple prescribers and saving or stockpiling unused medications.8

Analgesics for older patients

In general, there is limited evidence about the use of analgesic medications in older patients. Older patients are often specifically excluded from clinical trials because of their age, comorbidities or concurrent medications.

For all patient groups, timing of medication administration and duration of action is important. Severe, episodic pain requires treatment with medicines with a rapid onset of action and short duration. However, if a patient is experiencing continuous pain, regular analgesia is the most effective, possibly using modified-release formulations.436


Paracetamol

Paracetamol is recommended as a first-line therapy in older adults for mild to moderate pain. There is no evidence to support a need for dosage reduction of paracetamol in this group. Although there is emerging evidence of ineffectiveness of paracetamol in low back pain and some osteoarthritis conditions,295 these findings are disputed.


Non-steroidal anti-inflammatories

The use of non-selective NSAIDs is relatively contraindicated in older patients due to increased risk of gastric and renal side effects, as well as cardiovascular and cerebrovascular effects.437 However, individual circumstance and context may make these drugs an appropriate choice. A large 2010 study of patients with arthritis (mean age 80 years) found that overall, patients on NSAIDs appear to fare better than those taking opioids: the opioid cohort showed higher rates of fracture, hospital admission and all-cause mortality with similar or higher rates of cardiovascular, renal and gastrointestinal adverse effects.438

Judicious use is advised particularly in older patients;439 support with protective proton pump therapy is advised.440


Adjuvant therapies – Anticonvulsants

An increase in adverse effects with pregabalin appears to be dose related rather than associated with patient age. However, the initial doses of anticonvulsant drugs should be low and increases in dose should occur slowly. The reduction in renal function that occurs with increasing age means that the elimination of gabapentin and pregabalin may be reduced and lower doses required.

Monitoring of side effects is important, particularly for somnolence and dizziness with pregabalin, but the lack of hepatic metabolism and low drug interactions makes gabapentin and pregabalin useful in older patients.


Adjuvant therapies – Antidepressants

Caution should be exercised with TCAs as their clearance may decrease in older patients. Confusion and hypotension are more likely in this group due to increasing anticholinergic load. Lower initial doses are recommended with careful monitoring for side effects. Contraindications to TCAs include prostatic hypertrophy, narrow angle glaucoma, cardiovascular disease and impaired liver function.

Other antidepressants may be more appropriate: SNRIs (duloxetine) have shown to be effective and safe in older patients though care should be taken with poor renal function.


Opioid therapy

Appropriate precautions must be taken when considering opioid therapy for older patients.102 These precautions include lower starting doses, slower titration, longer dosing intervals, more frequent monitoring and tapering of benzodiazepines.78,102 There is an increased risk of adverse effects including cognitive impairment, sedation, respiratory depression and falls.441,442 The risk of respiratory depression is minimised by monitoring the patient for sedation and reducing the dose of opioid if this occurs.441

While there are large individual differences, older patients are more sensitive to opioids and dose requirement decreases progressively with age, often reduced by 50% or more. There may be fewer pharmacokinetic differences between older and younger patients with fentanyl requirements.445,446 In patients older than 75 years, the elimination half-life of tramadol is slightly prolonged447 and lower daily doses have been suggested.448


In practice

Older patients require less opioid medication than younger patients to achieve the same degree of pain relief; harms can also occur at lower doses than they occur in younger patients.445,446,449 However, inter-patient variability exists in all age groups and doses must be titrated to effect in all patients.

Patients with chronic renal disease frequently report pain450 and patients with cancer often develop severe renal impairment.451

Analgesics for patients with renal disease

Pain adjuvants

Pain adjuvants gabapentin and pregabalin require dose adjustments dependent on creatinine clearance.452

There is limited data on TCAs. Metabolite accumulation may occur and increase the risk of adverse effects but there is little evidence to indicate need for dose reduction. Duloxetine is avoided in patients with creatinine clearance <30 mL/min.453


Opioids

Prescribers should use additional caution and increased monitoring to minimise risks of opioid therapy in patients with renal insufficiency.8 While all patients on opioids should be monitored for adverse effects, there are particular opioids (or their metabolites) that are more likely to cause toxicity in patients with renal impairment.454 These include morphine, diamorphine and codeine derivatives.454

Hydromorphone, methadone, morphine and tramadol have been used in patients with renal disease but with dose adjustments depending on the degree of impairment.337 Tapentadol is not recommended for use with creatinine clearance <30 mL/min. Alternates to pethidine and dextropropoxyphene are recommended.455,456


In practice

The safest analgesics for patients with renal impairment are buprenorphine, fentanyl and paracetamol.337 These analgesics are not associated with high active metabolite load or significantly prolonged clearance. Oxycodone can usually be used without any dose adjustment as its metabolites do not appear to contribute to any clinical effect.337 Hydromorphone is used for patients undergoing dialysis.

Liver disease does not always equate with hepatic dysfunction, and there is no accurate measure of liver disease severity that can be used to guide dose adjustment.457

Analgesics for patients with liver disease

Paracetamol

Paracetamol is safe in patients with chronic liver disease, but a reduced dose of 2–3 g daily is recommended for long-term use.457


Pain adjuvants

Adjuvant analgesics such as TCAs and anticonvulsants may be used cautiously for cirrhotic patients with neuropathic pain.458 Gabapentin or pregabalin may be better tolerated in cirrhosis because of non-hepatic metabolism and a lack of anticholinergic side effects.458


Opioids

Prescribers should use additional caution and increased monitoring to minimise risks of opioids in patients with hepatic insufficiency.8 In these patients, opioids are well known to cause sedation, constipation and precipitate encephalopathy. There is an increased risk for patients with hypoalbuminaemia, and immediate-release as opposed to controlled-release formulations are advised.458

Mild pain not controlled with paracetamol may be best managed with either low-dose tramadol or oxycodone (not slow-release formulation) with an increase in laxatives.458 Fentanyl and buprenorphine are also considered relatively safe. However, combined preparations of slow-release oxycodone and naloxone are not recommended.

In practice

Co-prescription of laxatives is mandatory to avoid constipation and encephalopathy in patients with hepatic insufficiency.

Culturally responsive care

Culture, language and religious convictions have an impact on pain sensitivities, assessment and management. There are significant cultural differences in self-care when managing pain, which affect pain relief seeking behaviour.459,460

Given the large inter-individual differences in pain behaviours and analgesic requirements in any patient group, pain should be assessed and managed on an individual basis rather than expectations associated with any cultural or ethnic group.461,462

There are genetic differences (refer to Prescribing drugs of dependence in general practice, Part C1: Opioids – Section 3.1.2 Metabolism and duration of activity) in the metabolism of opioids,349,463,464 which also need to be considered.

Prescribing opioids to Aboriginal and Torres Strait Islander peoples

High-quality literature to inform acute pain management and opioid use in Aboriginal and Torres Strait Islander peoples is limited or conflicting.465–468

As with all patients, comorbidities need to be considered when selecting analgesics. Higher levels of medical comorbidities such as renal failure have been identified within the Aboriginal and Torres Strait Islander population.469

In practice

Non-Indigenous GPs should consider seeking the assistance of an Aboriginal health worker or an interpreter to assist in communication and cross-cultural understandings (as needed).470,471

Many people experiencing long-term pain may have a range of chronic health conditions, including mental health issues.472 For example, the AIHW (2016) reports that three in 10 people living with back pain are living with mental health issues, which is twice the rate of the general population.473

Depression is the most common mental health comorbidity with long-term pain. It is associated with poorer quality of life and increased functional impairment.474 Diagnosis may be challenging as there are indistinct symptom boundaries between chronic pain, distress and depression.475

Chronic pain is associated with a range of other psychological problems including anxiety, somatisation, fear of pain, anger and hostility.476 Around one-third (31.8%) of people with a psychotic disorder in Australia are also experiencing chronic pain.477

Patients may present with pain as a manifestation of mental health problems. However, opioids should be reserved for well-defined somatic or neuropathic pain conditions.411

Patients with a mental health disorder, including SUDs, are at greater risk of adverse effects from opioid treatment. Prescribers should use additional caution and increased monitoring: titrate more slowly and seek consultant advice where feasible.8,78

Before prescribing opioids, a thorough evaluation for contraindications to opioids is recommended.101 Treatment of anxiety and depression should be optimised prior to initiation of opioids.8 The concomitant use of benzodiazepines should be avoided;101 tapering of benzodiazepines or referral is suggested before starting opioid therapy.90

GPs should review patients’ histories of controlled substance prescriptions using PDMP data to determine whether they are receiving opioid dosages or dangerous combinations that put them at high risk for overdose.

In practice

Prescribers should use additional caution and increased monitoring: titrate more slowly and seek appropriate advice. Referral to mental health and/or pain medicine specialist is recommended for patients with:101

  • mental and behavioural health disorders
  • SUDs
  • uncontrolled or severe psychiatric disorders
  • suicidal ideation or actions
  • significant medical comorbidities
  • adverse behavioural or cognitive effects.

There is an issue with accessibility to services in many areas, but this should not be a reason for lack of consultation.

Multidisciplinary care and maximal use of non-pharmacological and non-opioid therapies to address analgesia should be undertaken. Optimise therapies to address mental health conditions. Consider low ceiling doses for opioids and naloxone therapy.

Stratification of patients into high-risk, medium-risk, and low-risk categories is important prior to consideration of initiation and maintenance of opioid therapy. Risk stratification is justified in all patients who are likely to undergo long-term opioid therapy due to the significant proportion of potential harm, misuse and abuse.

In practice

Risk stratification should be considered as part of a clinical evaluation for opioid therapy. Stratifications aids in decisions regarding risk modification therapies (eg naloxone) and referral.

  1. Cohen M, Quintner J, Buchanan D. Is chronic pain a disease? Pain Med 2013;14(9):1284–88.
  2. Upshur CC, Luckmann RS, Savageau JA. Primary care provider concerns about management of chronic pain in community clinic populations. J Gen Intern Med 2006;21(6):652–55.
  3. Henderson JV, Harrison CM, Britt HC, Bayram CF, Miller GC. Prevalence, causes, severity, impact, and management of chronic pain in Australian general practice patients. Pain Med 2013;14(9):1346–61.
  4. O’Rorke JE, Chen I, Genao I, Panda M, Cykert S. Physicians’ comfort in caring for patients with chronic nonmalignant pain. Am J Med Sci 2007;333(2):93–100.
  5. Australian and New Zealand College of Anaesthetists. Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain. Melbourne: ANZCA, 2015 PM1-2010.pdf [Accessed 19 July 2017].
  6. Guyatt GH, Oxman AD, Vist GE, et al. GRADE: An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008;336(7650):924–26.
  7. Schug S, Palmer G, Scott D, et al. Acute pain management: Scientific evidence. 4th edn. Melbourne: ANZCA, 2015 Documents/APMSE4_2015_Final [Accessed 19 July 2017].
  8. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. JAMA 2016;315(15):1624–45.
  9. Saragiotto BT, Machado GC, Ferreira ML, Pinheiro MB, Abdel Shaheed C, Maher CG. Paracetamol for low back pain. Cochrane Database Syst Rev 2016(6):CD012230.
  10. Williams CM, Maher CG, Latimer J, et al. Efficacy of paracetamol for acute low-back pain: A double-blind, randomised controlled trial. Lancet 2014;384(9954):1586–96.
  11. Moore RA, Derry S, Aldington D, Wiffen PJ. Single dose oral analgesics for acute postoperative pain in adults – An overview of Cochrane reviews. Cochrane Database Syst Rev 2015(9):CD008659.
  12. Moore RA, Derry S, Wiffen PJ, Straube S, Aldington DJ. Overview review: Comparative efficacy of oral ibuprofen and paracetamol (acetaminophen) across acute and chronic pain conditions. Eur J Pain 2015;19(9):1213–23.
  13. Moore RA, Derry S, Aldington D, Wiffen PJ. Adverse events associated with single dose oral analgesics for acute postoperative pain in adults – An overview of Cochrane reviews. Cochrane Database Syst Rev 2015(10):CD011407.
  14. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: A qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010;110(4):1170–79.
  15. Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth. Cochrane Database Syst Rev 2013;12:CD004624.
  16. Shaheed CA, Maher CG, McLachlan AJ. Investigating the efficacy and safety of over-the-counter codeine containing combination analgesics for pain and codeine based antitussives. Canberra: Therapeutic Goods Association, 2016 [Accessed 19 July 2017].
  17. Blondell RD, Azadfard M, Wisniewski AM. Pharmacologic therapy for acute pain. Am Fam Physician 2013;87(11):766–72.
  18. Bendtsen L, Evers S, Linde M, et al. EFNS guideline on the treatment of tension-type headache – Report of an EFNS task force. Eur J Neurol 2010;17(11):1318–25.
  19. Thorson D, Biewen P, Bonte B, et al. Acute pain assessment and opioid prescribing protocol. Bloomington, MN: Institute for Clinical Systems Improvement, 2014 Opioids.pdf [Accessed 1 September 2017].
  20. Australian and New Zealand College of Anaesthetists. Guidelines on acute pain management. Melbourne: ANZCA, 2013 Documents/ps41-2013-guidelines-on-acute-painmanagement [Accessed 19 July 2017].
  21. Traeger AC, Hubscher M, Henschke N, Moseley GL, Lee H, McAuley JH. Effect of primary care-based education on reassurance in patients with acute low back pain: Systematic review and meta-analysis. JAMA Intern Med 2015;175(5):733–43.
  22. Qaseem A, Wilt TJ, McLean RM, Forciea MA, Clinical Guidelines Committee of the American College of Physicians. Noninvasive treatments for acute, subacute, and chronic low back pain: A clinical practice guideline from the American College of Physicians. Ann Intern Med 2017;166(7):514–30.
  23. Chung JW, Zeng Y, Wong TK. Drug therapy for the treatment of chronic nonspecific low back pain: Systematic review and meta-analysis. Pain Physician 2013;16(6):E685–704.
  24. van den Bekerom MP, Sjer A, Somford MP, Bulstra GH, Struijs PA, Kerkhoffs GM. Non-steroidal anti-inflammatory drugs (NSAIDs) for treating acute ankle sprains in adults: Benefits outweigh adverse events. Knee Surg Sports Traumatol Arthrosc 2015;23(8):2390–99.
  25. Massey T, Derry S, Moore RA, McQuay HJ. Topical NSAIDs for acute pain in adults. Cochrane Database Syst Rev 2010(6):CD007402.
  26. Predel HG, Giannetti B, Seigfried B, Novellini R, Menke G. A randomized, double-blind, placebo-controlled multicentre study to evaluate the efficacy and safety of diclofenac 4%
  27. spray gel in the treatment of acute uncomplicated ankle sprain. J Int Med Res 2013;41(4):1187–202.
  28. Predel HG, Hamelsky S, Gold M, Giannetti B. Efficacy and safety of diclofenac diethylamine 2.32% gel in acute ankle sprain. Med Sci Sports Exerc 2012;44(9):1629–36.
  29. Serinken M, Eken C, Turkcuer I, Elicabuk H, Uyanik E, Schultz CH. Intravenous paracetamol versus morphine for renal colic in the emergency department: A randomised double-blind controlled trial. Emerg Med J 2012;29(11):902–95.
  30. Holdgate A, Pollock T. Nonsteroidal anti-inflammatory drugs (NSAIDs) versus opioids for acute renal colic. Cochrane Database Syst Rev 2005(2):CD004137.
  31. Afshar K, Jafari S, Marks AJ, Eftekhari A, MacNeily AE. Nonsteroidal anti-inflammatory drugs (NSAIDs) and nonopioids for acute renal colic. Cochrane Database Syst Rev 2015(6):CD006027.
  32. Turk C, Petrik A, Sarica K, et al. EAU guidelines on diagnosis and conservative management of urolithiasis. Eur Urol 2016;69(3):468–74.
  33. Sin B, Koop K, Liu M, Yeh JY, Thandi P. Intravenous acetaminophen for renal colic in the emergency department: Where do we stand? Am J Ther 2017;24(1):e12–e19.
  34. Campschroer T, Zhu Y, Duijvesz D, Grobbee DE, Lock MT. Alpha-blockers as medical expulsive therapy for ureteral stones. Cochrane Database Syst Rev 2014;4:CD008509.
  35. Colli A, Conte D, Valle SD, Sciola V, Fraquelli M. Metaanalysis: Nonsteroidal anti-inflammatory drugs in biliary colic. Aliment Pharmacol Ther 2012;35(12):1370–78.
  36. National Institute for Health and Clinical Excellence. Gallstone disease: Diagnosis and initial management. NICE guidelines CG188. London: NICE, 2014. Available at www. [Accessed 21 July 2017].
  37. Zakko SF. Uncomplicated gallstone disease in adults. UpToDate, 2016 uncomplicated-gallstone-disease-in-adults?topicKey=GAST %2F654&elapsedTimeMs=5&source=machineLearning&se archTerm=biliary+colic&selectedTitle=1%7E150&view=print &displayedView=full&anchor=H25 [Accessed 21 July 2017].
  38. Moore PA, Hersh EV. Combining ibuprofen and acetaminophen for acute pain management after thirdmolar extractions: Translating clinical research to dental practice. J Am Dent Assoc 2013;144(8):898–908.
  39. Marjoribanks J, Proctor M, Farquhar C, Derks RS.
  40. Nonsteroidal anti-inflammatory drugs for dysmenorrhoea. Cochrane Database Syst Rev 2010(1):CD001751.
  41. Cunningham A, Breuer J, Dwyer D, et al. The prevention and management of herpes zoster. Med J Aust 2008;188(3):171–76.
  42. Dworkin RH, Johnson RW, Breuer J, et al.
  43. Recommendations for the management of herpes zoster. Clin Infect Dis 2007;44(Suppl 1):S1–26.
  44. Dwyer DE, Cunningham AL. 10: Herpes simplex and varicella-zoster virus infections. Med J Aust 2002;177(5):267–73.
  45. Berry JD, Petersen KL. A single dose of gabapentin reduces acute pain and allodynia in patients with herpes zoster. Neurology 2005;65(3):444–47.
  46. Jensen-Dahm C, Rowbotham MC, Reda H, Petersen KL.
  47. Effect of a single dose of pregabalin on herpes zoster pain. Trials 2011;12:55.
  48. Lin PL, Fan SZ, Huang CH, et al. Analgesic effect of lidocaine patch 5% in the treatment of acute herpes zoster: A double-blind and vehicle-controlled study. Reg Anesth Pain Med 2008;33(4):320–25.
  49. Chen N, Li Q, Yang J, Zhou M, Zhou D, He L. Antiviral treatment for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2014(2):CD006866.
  50. Chen N, Yang M, He L, Zhang D, Zhou M, Zhu C.
  51. Corticosteroids for preventing postherpetic neuralgia. Cochrane Database Syst Rev 2010(12):CD005582.
  52. Saarto T, Wiffen PJ. Antidepressants for neuropathic pain: A Cochrane review. J Neurol Neurosurg Psychiatry 2010;81(12):1372–73.
  53. Moore RA, Derry S, Wiffen PJ, Straube S, Bendtsen L. Evidence for efficacy of acute treatment of episodic tensiontype headache: Methodological critique of randomised trials for oral treatments. Pain 2014;155(11):2220–28.
  54. Chaibi A, Russell MB. Manual therapies for cervicogenic headache: A systematic review. J Headache Pain 2012;13(5):351–59.
  55. Luedtke K, Allers A, Schulte LH, May A. Efficacy of interventions used by physiotherapists for patients with headache and migraine-systematic review and metaanalysis. Cephalalgia 2016;36(5):474–92.
  56. Derry S, Moore RA. Paracetamol (acetaminophen) with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2013;4:CD008040.
  57. Kirthi V, Derry S, Moore RA. Aspirin with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2013;4:CD008041.
  58. Rabbie R, Derry S, Moore RA. Ibuprofen with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2013;4:CD008039.
  59. Derry S, Rabbie R, Moore RA. Diclofenac with or without an antiemetic for acute migraine headaches in adults. Cochrane Database Syst Rev 2013;4:CD008783.
  60. Colman I, Brown MD, Innes GD, Grafstein E, Roberts TE, Rowe BH. Parenteral metoclopramide for acute migraine: Meta-analysis of randomised controlled trials. BMJ 2004;329(7479):1369–73.
  61. Friedman BW, Esses D, Solorzano C, et al. A randomized controlled trial of prochlorperazine versus metoclopramide for treatment of acute migraine. Ann Emerg Med 2008;52(4):399–406.
  62. Coppola M, Yealy DM, Leibold RA. Randomized, placebo-controlled evaluation of prochlorperazine versus metoclopramide for emergency department treatment of migraine headache. Ann Emerg Med 1995;26(5):541–46.
  63. Taggart E, Doran S, Kokotillo A, Campbell S, Villa-Roel C, Rowe BH. Ketorolac in the treatment of acute migraine: A systematic review. Headache 2013;53(2):277–87.
  64. Thorlund K, Mills EJ, Wu P, et al. Comparative efficacy of triptans for the abortive treatment of migraine: A multiple treatment comparison meta-analysis. Cephalalgia 2014;34(4):258-67.
  65. Tepper SJ. Opioids should not be used in migraine. Headache 2012;52(Suppl 1):30–34.
  66. Buse DC, Pearlman SH, Reed ML, Serrano D, Ng-Mak DS, Lipton RB. Opioid use and dependence among persons with migraine: Results of the AMPP study. Headache 2012;52(1):18–36.
  67. Finocchi C, Viani E. Opioids can be useful in the treatment of headache. Neurol Sci 2013;34(Suppl 1):S119–24.
  68. Broner SW, Sun-Edelstein C, Lay CL. Cluster headache in women. Curr Pain Headache Rep 2007;11(2):127–30.
  69. Finkel AG. Epidemiology of cluster headache. Curr Pain Headache Rep 2003;7(2):144–49.
  70. Fischera M, Marziniak M, Gralow I, Evers S. The incidence and prevalence of cluster headache: A meta-analysis of population-based studies. Cephalalgia 2008;28(6):614–18.
  71. Bennett MH, French C, Schnabel A, Wasiak J, Kranke P. Normobaric and hyperbaric oxygen therapy for migraine and cluster headache. Cochrane Database Syst Rev 2008(3):CD005219.
  72. Cohen AS, Burns B, Goadsby PJ. High-flow oxygen for treatment of cluster headache: A randomized trial. JAMA 2009;302(22):2451–57.
  73. Robbins MS, Starling AJ, Pringsheim TM, Becker WJ,
  74. Schwedt TJ. Treatment of cluster headache: American Headache Society evidence-based guidelines. Headache 2016;56(7):1093–106.
  75. Bennett MH, French C, Schnabel A, Wasiak J, Kranke P, Weibel S. Normobaric and hyperbaric oxygen therapy for the treatment and prevention of migraine and cluster headache. Cochrane Database Syst Rev 2015(12):CD005219.
  76. Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rev 2013;7:CD008042.
  77. Francis GJ, Becker WJ, Pringsheim TM. Acute and preventive pharmacologic treatment of cluster headache. Neurology 2010;75(5):463–73.
  78. van der Meer HA, Speksnijder CM, Engelbert R,
  79. Lobbezoo F, Nijhuis-van der Sanden MW, Visscher CM. The association between headaches and temporomandibular disorders is confounded by bruxism and somatic complaints. Clin J Pain 2016. doi: 10.1097/ AJP.0000000000000470.
  80. Costa YM, Conti PC, de Faria FA, Bonjardim LR.
  81. Temporomandibular disorders and painful comorbidities: Clinical association and underlying mechanisms. Oral Surg Oral Med Oral Pathol Oral Radiol 2017;123(3):288–97.
  82. Schiffman E, Ohrbach R, List T, et al. Diagnostic criteria for headache attributed to temporomandibular disorders. Cephalalgia 2012;32(9):683–92.
  83. Mujakperuo HR, Watson M, Morrison R, Macfarlane TV.
  84. Pharmacological interventions for pain in patients with temporomandibular disorders. Cochrane Database Syst Rev 2010(10):CD004715.
  85. Ta LE, Dionne RA. Treatment of painful temporomandibular joints with a cyclooxygenase-2 inhibitor: A randomized placebo-controlled comparison of celecoxib to naproxen. Pain 2004;111(1-2):13–21.
  86. Kelley JM, Kraft-Todd G, Schapira L, Kossowsky J, Riess H. The influence of the patient-clinician relationship on healthcare outcomes: A systematic review and metaanalysis of randomized controlled trials. PLoS One 2014;9(4):e94207.
  87. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Part B: Recommendations for practice. Ontario:
  88. NOUGG, 2010. Available at http://nationalpaincentre. [Accessed 21 July 2017].
  89. Klinger R, Colloca L, Bingel U, Flor H. Placebo analgesia: Clinical applications. Pain 2014;155(6):1055–58.
  90. Miller FG, Kaptchuk TJ. The power of context: Reconceptualizing the placebo effect. J R Soc Med 2008;101(5):222–25.
  91. Lee C, Crawford C, Swann S, Active Self-Care Therapies for Pain Working Group. Multimodal, integrative therapies for the self-management of chronic pain symptoms. Pain Med 2014;15(Suppl 1):S76–85.
  92. Hayden JA, van Tulder MW, Malmivaara A, Koes BW. Exercise therapy for treatment of non-specific low back pain. Cochrane Database Syst Rev 2005(3):CD000335.
  93. Fransen M, McConnell S, Harmer AR, Van der Esch M, Simic M, Bennell KL. Exercise for osteoarthritis of the knee: A Cochrane systematic review. Br J Sports Med 2015;49(24):1554–57.
  94. Fransen M, McConnell S, Hernandez-Molina G,
  95. Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database Syst Rev 2014;4:CD007912.
  96. Busch AJ, Barber KA, Overend TJ, Peloso PM, Schachter CL. Exercise for treating fibromyalgia syndrome. Cochrane Database Syst Rev 2007(4):CD003786.
  97. Scottish Intercollegiate Guidelines Network. Management of chronic pain (SIGN 136). Edinburgh: SIGN, 2013 [Accessed 1 September 2017].
  98. Williams AC, Eccleston C, Morley S. Psychological therapies for the management of chronic pain (excluding headache) in adults. Cochrane Database Syst Rev 2012;11:CD007407.
  99. Eccleston C, Hearn L, Williams AC. Psychological therapies for the management of chronic neuropathic pain in adults. Cochrane Database Syst Rev 2015;10:CD011259.
  100. Hooten W, Timming R, Belgrade M, et al. Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement, 2013 c26a36d83686607ad89ee835daa3c9db3f4c.pdf [Accessed 1 September 2017].
  101. Kahan M, Mailis-Gagnon A, Wilson L, Srivastava A, National
  102. Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: Clinical summary for family physicians. Part 1: General population. Can Fam Physician 2011;57(11):1257–66, e407-18.
  103. The Royal Australasian College of Physicians. Prescription opioid policy: Improving management of chronic nonmalignant pain and prevention of problems associated with prescription opioid use. Sydney: RACP, 2009.
  104. Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2: Guidance. Pain Physician 2012;15(3 Suppl):S67–116.
  105. National Center for Injury Prevention and Control. Common elements in guidelines for prescribing opioids for chronic pain. NCIPC, 2014 drugoverdose/pdf/common_elements_in_guidelines_for_ prescribing_opioids-a.pdf [Accessed 21 July 2017].
  106. Moulin D, Boulanger A, Clark AJ, et al. Pharmacological management of chronic neuropathic pain: Revised consensus statement from the Canadian Pain Society. Pain Res Manag 2014;19(6):328–35.
  107. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: A systematic review and meta-analysis. JAMA. 2015;313(24):2456-73.
  108. Finnerup NB, Attal N, Haroutounian S, et al. Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis. Lancet Neurol 2015;14(2):162–73.
  109. Australian and New Zealand College of Anaesthetists. Statement on ‘medicinal cannabis’ with particular reference to its use in the management of patients with chronic noncancer pain (PM10). Melbourne: ANZCA, 2015 [Accessed 21 July 2017].
  110. Stacey BR, Barrett JA, Whalen E, Phillips KF, Rowbotham MC. Pregabalin for postherpetic neuralgia: Placebocontrolled trial of fixed and flexible dosing regimens on allodynia and time to onset of pain relief. J Pain 2008;9(11):1006–17.
  111. Wang F, Ruberg SJ, Gaynor PJ, Heinloth AN, Arnold LM. Early improvement in pain predicts pain response at endpoint in patients with fibromyalgia. J Pain 2011;12(10):1088–94.
  112. Therapeutics Initiative. Benefits and harms of drugs for ‘neuropathic’ pain. Vancouver: University of British Columbia, 2015 [Accessed 21 July 2017].
  113. Hughes MA, Biggs JJ, Theise MS, Graziano K, Robbins RB, Effiong AC. Recommended opioid prescribing practices for use in chronic non-malignant pain: A systematic review of treatment guidelines. J Manag Care Med 2011;14(3):52.
  114. National Opioid Use Guideline Group. Canadian guideline for safe and effective use of opioids for chronic non-cancer pain. Ontario: NOUGG, 2010. Available at http://nationalpaincentre. [Accessed 21 July 2017].
  115. Deyo RA, Von Korff M, Duhrkoop D. Opioids for low back pain. BMJ 2015;350:g6380.
  116. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009;10(2):113–30.
  117. Fagan MJ, Chen JT, Diaz JA, Reinert SE, Stein MD. Do internal medicine residents find pain medication agreements useful? Clin J Pain 2008;24(1):35–38.
  118. Bazazi AR, Zaller ND, Fu JJ, Rich JD. Preventing opiate overdose deaths: Examining objections to takehome naloxone. J Health Care Poor Underserved 2010;21(4):1108–13.
  119. McDonald R, Strang J. Are take-home naloxone programmes effective? Systematic review utilizing application of the Bradford Hill criteria. Addiction 2016;111(7):1177–87.
  120. Strang J, McDonald R, Alqurshi A, Royall P, Taylor D, Forbes B. Naloxone without the needle – Systematic review of candidate routes for non-injectable naloxone for opioid overdose reversal. Drug Alcohol Depend 2016;163:16–23.
  121. Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med 2009;24(6):733–38.
  122. Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf 2009;18(12):1166–75.
  123. Smith HS, Peppin JF. Toward a systematic approach to opioid rotation. J Pain Res 2014;7:589–608.
  124. The British Pain Society. Opioids for persistent pain: Good practice. London: The British Pain Society, 2010.
  125. Becker WC, Fraenkel L, Edelman EJ, et al. Instruments to assess patient-reported safety, efficacy, or misuse of current opioid therapy for chronic pain: A systematic review. Pain 2013;154(6):905–16.
  126. Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: A rational approach to the treatment of chronic pain. Pain Med 2005;6(2):107–12.
  127. Jammal W, Gown G. Opioid prescribing pitfalls: Medicolegal and regulatory issues. Aust Prescr 2015;38:198–203.
  128. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010(1):CD006605.
  129. Häuser W, Bock F, Engeser P, Tölle T, Willweber-Strumpf A, Petzke F. Long-term opioid use in non-cancer pain. Dtsch Ärztebl Int 2014;111(43):732–40.
  130. Tawfic Q, Kumar K, Pirani Z, Armstrong K. Prevention of chronic post-surgical pain: The importance of early identification of risk factors. J Anesth 2017;31(3):424–31.
  131. Wylde V, Hewlett S, Learmonth ID, Dieppe P. Persistent pain after joint replacement: Prevalence, sensory qualities, and postoperative determinants. Pain 2011;152(3):566–72.
  132. Chan MT, Wan AC, Gin T, Leslie K, Myles PS. Chronic postsurgical pain after nitrous oxide anesthesia. Pain 2011;152(11):2514–20.
  133. Macrae WA. Chronic post-surgical pain: 10 years on. Br J Anaesth 2008;101(1):77–86.
  134. Kehlet H, Jensen TS, Woolf CJ. Persistent postsurgical pain: Risk factors and prevention. Lancet 2006;367(9522):1618–25.
  135. Treede RD, Rief W, Barke A, et al. A classification of chronic pain for ICD-11. Pain 2015;156(6):1003–7.
  136. Theunissen M, Peters ML, Bruce J, Gramke HF, Marcus MA. Preoperative anxiety and catastrophizing: A systematic review and meta-analysis of the association with chronic postsurgical pain. Clin J Pain 2012;28(9):819–41.
  137. Hinrichs-Rocker A, Schulz K, Jarvinen I, Lefering R, Simanski C, Neugebauer EA. Psychosocial predictors and correlates for chronic post-surgical pain (CPSP) – A systematic review. Eur J Pain 2009;13(7):719–30.
  138. Buchheit T, Van de Ven T, Shaw A. Epigenetics and the transition from acute to chronic pain. Pain Med 2012;13(11):1474–90.
  139. Mauck M, Van de Ven T, Shaw AD. Epigenetics of chronic pain after thoracic surgery. Curr Opin Anaesthesiol 2014;27(1):1–5.
  140. Wesselmann U, Baranowski AP, Borjesson M, et al.
  141. Emerging therapies and novel approaches to visceral pain. Drug Discov Today Ther Strateg 2009;6(3):89–95.
  142. Olesen AE, Farmer AD, Olesen SS, Aziz Q, Drewes AM. Management of chronic visceral pain. Pain Manag 2016;6(5):469–86.
  143. Queiroz LP. Worldwide epidemiology of fibromyalgia. Curr Pain Headache Rep 2013;17(8):356.
  144. Hauser W, Zimmer C, Felde E, Kollner V. What are the key symptoms of fibromyalgia? Results of a survey of the German Fibromyalgia Association. Schmerz 2008;22(2):176–83.
  145. Clauw DJ, Arnold LM, McCarberg BH, FibroCollaborative. The science of fibromyalgia. Mayo Clin Proc 2011;86(9):907–11.
  146. Macfarlane GJ, Kronisch C, Dean LE, et al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis 2017;76(2):318–28.
  147. Angel Garcia D, Martinez Nicolas I, Saturno Hernandez PJ. Clinical approach to fibromyalgia: Synthesis of evidencebased recommendations, a systematic review. Reumatol Clin 2016;12(2):65–71.
  148. Clauw DJ. Fibromyalgia: A clinical review. JAMA 2014;311(15):1547–55.
  149. Fitzcharles MA, Ste-Marie PA, Goldenberg DL, et al. 2012 Canadian guidelines for the diagnosis and management of fibromyalgia syndrome: Executive summary. Pain Res Manag 2013;18(3):119–26.
  150. Hauser W, Thieme K, Turk DC. Guidelines on the management of fibromyalgia syndrome – A systematic review. Eur J Pain 2010;14(1):5–10.
  151. Goebel A, Barker C, Turner-Stokes L, et al. Complex regional pain syndrome in adults: UK guidelines for diagnosis, referral and management in primary and secondary care. London: RCP, 2012.
  152. Casale R, Atzeni F, Sarzi-Puttini P. The therapeutic approach to complex regional pain syndrome: Light and shade. Clin Exp Rheumatol 2015;33(1 Suppl 88):S126–39.
  153. Birklein F, O’Neill D, Schlereth T. Complex regional pain syndrome: An optimistic perspective. Neurology 2015;84(1):89–96.
  154. Borchers AT, Gershwin ME. Complex regional pain syndrome: A comprehensive and critical review. Autoimmun Rev 2014;13(3):242–65.
  155. Lohnberg JA, Altmaier EM. A review of psychosocial factors in complex regional pain syndrome. J Clin Psychol Med Settings 2013;20(2):247–54.
  156. Cossins L, Okell RW, Cameron H, Simpson B, Poole HM, Goebel A. Treatment of complex regional pain syndrome in adults: A systematic review of randomized controlled trials published from June 2000 to February 2012. Eur J Pain 2013;17(2):158–73.
  157. Goh EL, Chidambaram S, Ma D. Complex regional pain syndrome: A recent update. Burns Trauma 2017;5:2.
  158. Larochelle MR, Liebschutz JM, Zhang F, Ross-Degnan D, Wharam JF. Opioid prescribing after nonfatal overdose and association with repeated overdose: A cohort study. Ann Intern Med 2016;164(1):1–9.
  159. Zanini C, Sarzi-Puttini P, Atzeni F, Di Franco M, Rubinelli S. Building bridges between doctors and patients: The design and pilot evaluation of a training session in argumentation for chronic pain experts. BMC Med Educ 2015;15:89.
  160. Gammaitoni AR, Fine P, Alvarez N, McPherson ML, Bergmark S. Clinical application of opioid equianalgesic data. Clin J Pain 2003;19(5):286–97.
  161. NSW Therapeutic Advisory Group Inc. Preventing and managing problems with opioid prescribing for chronic noncancer pain. Sydney: NSW TAG, 2015. Available at www. practical-guidance/pain-guidance-july-2015.pdf [Accessed 26 July 2017].
  162. Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;189(18):E659–E66.
  163. Windmill J, Fisher E, Eccleston C, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev 2013(9):CD010323.
  164. Nilsen HK, Stiles TC, Landro NI, Fors EA, Kaasa S, Borchgrevink PC. Patients with problematic opioid use can be weaned from codeine without pain escalation. Acta Anaesthesiol Scand 2010;54(5):571–79.
  165. Baron MJ, McDonald PW. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Manag 2006;2(5):277–82.
  166. Crisostomo RA, Schmidt JE, Hooten WM, Kerkvliet JL, Townsend CO, Bruce BK. Withdrawal of analgesic medication for chronic low-back pain patients: Improvement in outcomes of multidisciplinary rehabilitation regardless of surgical history. Am J Phys Med Rehabil 2008;87(7):527–36.
  167. Younger J, Barelka P, Carroll I, et al. Reduced cold pain tolerance in chronic pain patients following opioid detoxification. Pain Med 2008;9(8):1158–63.
  168. Hooten WM, Mantilla CB, Sandroni P, Townsend CO. Associations between heat pain perception and opioid dose among patients with chronic pain undergoing opioid tapering. Pain Med 2010;11(11):1587–98.
  169. Wang H, Akbar M, Weinsheimer N, Gantz S, Schiltenwolf M. Longitudinal observation of changes in pain sensitivity during opioid tapering in patients with chronic low-back pain. Pain Med 2011;12(12):1720–26.
  170. Berna C, Kulich RJ, Rathmell JP. Tapering long-term opioid therapy in chronic noncancer pain: Evidence and recommendations for everyday practice. Mayo Clin Proc 2015;90(6):828–42.
  171. International Association for the Study of Pain. Classification of chronic pain. 2nd edn. Washington DC: IASP, 2011 aspx?ItemNumber=1673 [Accessed 26 July 2017].
  172. Katz J, Weinrib A, Fashler SR, et al. The Toronto General Hospital Transitional Pain Service: Development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res 2015;8:695–702.
  173. Denk F, McMahon SB, Tracey I. Pain vulnerability: A neurobiological perspective. Nat Neurosci 2014;17(2):192– 200.
  174. Eisenberger NI. The neural bases of social pain: Evidence for shared representations with physical pain. Psychosom Med 2012;74(2):126–35.
  175. Kosek E, Cohen M, Baron R, et al. Do we need a third mechanistic descriptor for chronic pain states? Pain 2016;157:1382–86.
  176. Merskey H, Bogduk N. International Association for the Study of Pain Task Force on Taxonomy. Classification of chronic pain: Descriptions of chronic pain syndromes and definitions of pain terms. 2nd edn. Seattle: IASP Press, 1994; p. 222.
  177. Smart KM, Blake C, Staines A, Thacker M, Doody C. Mechanisms-based classifications of musculoskeletal pain: Part 3 of 3: Symptoms and signs of nociceptive pain in patients with low back (+/– leg) pain. Man Ther 2012;17(4):352–57.
  178. Costigan M, Scholz J, Woolf CJ. Neuropathic pain: A maladaptive response of the nervous system to damage. Annu Rev Neurosci 2009;32:1–32.
  179. Freynhagen R, Baron R, Gockel U, Tolle TR. painDETECT: A new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006;22(10):1911–20.
  180. O’Connor AB, Dworkin RH. Treatment of neuropathic pain: An overview of recent guidelines. Am J Med 2009;122(10 Suppl):S22–32.
  181. Arendt-Nielsen L, Nie H, Laursen MB, et al. Sensitization in patients with painful knee osteoarthritis. Pain 2010; 149(3):573–81.
  182. Kosek E, Ordeberg G. Lack of pressure pain modulation by heterotopic noxious conditioning stimulation in patients with painful osteoarthritis before, but not following, surgical pain relief. Pain 2000;88(1):69–78.
  183. Aranda-Villalobos P, Fernandez-de-Las-Penas C, NavarroEspigares JL, et al. Normalization of widespread pressure pain hypersensitivity after total hip replacement in patients with hip osteoarthritis is associated with clinical and functional improvements. Arthritis Rheum 2013;65(5):1262–70.
  184. Graven-Nielsen T, Wodehouse T, Langford RM, ArendtNielsen L, Kidd BL. Normalization of widespread hyperesthesia and facilitated spatial summation of deep-tissue pain in knee osteoarthritis patients after knee replacement. Arthritis Rheum 2012;64(9):2907–16.
  185. Kosek E, Ordeberg G. Abnormalities of somatosensory perception in patients with painful osteoarthritis normalize following successful treatment. Eur J Pain 2000;4(3):229–38.
  186. Rosenquist EWK. Evaluation of chronic pain in adults. UpToDate 2016 evaluation-of-chronic-pain-in-adults?source=search_ result&search=pain%20assessment&selectedTitle=1~150 - H15544430 [Accessed 3 March 2017].
  187. Kirsh KL, Jass C, Bennett DS, Hagen JE, Passik SD. Initial development of a survey tool to detect issues of chemical coping in chronic pain patients. Palliat Support Care 2007;5(3):219–26.
  188. Flor H. Psychological pain interventions and neurophysiology: Implications for a mechanism-based approach. Am Psychol 2014;69(2):188–96.
  189. Nicholas MK, Linton SJ, Watson PJ, Main CJ, Decade of the Flags Working Group. Early identification and management of psychological risk factors (‘yellow flags’) in patients with low back pain: A reappraisal. Phys Ther 2011;91(5):737–53.
  190. Ip HY, Abrishami A, Peng PW, Wong J, Chung F. Predictors of postoperative pain and analgesic consumption: A qualitative systematic review. Anesthesiology 2009;111(3):657–77.
  191. Leeuw M, Goossens ME, Linton SJ, Crombez G, Boersma K, Vlaeyen JW. The fear-avoidance model of musculoskeletal pain: Current state of scientific evidence. J Behav Med 2007;30(1):77–94.
  192. Hjermstad MJ, Fayers PM, Haugen DF, et al. Studies comparing numerical rating scales, verbal rating scales, and visual analogue scales for assessment of pain intensity in adults: A systematic literature review. J Pain Symptom Manage 2011;41(6):1073–93.
  193. Chen L, Vo T, Seefeld L, et al. Lack of correlation between opioid dose adjustment and pain score change in a group of chronic pain patients. J Pain 2013;14(4):384–92.
  194. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015;162(4):276–86.
  195. Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: A review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician 2012;15(3 Suppl):ES67–92.
  196. Gordon A, Cone EJ, DePriest AZ, Axford-Gatley RA, Passik SD. Prescribing opioids for chronic noncancer pain in primary care: Risk assessment. Postgrad Med 2014;126(5):159–66.
  197. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects
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