Prescribing drugs of dependence in general practice

Part C2 - The role of opioids in pain management

A summary of opioid use in chronic non-cancer pain in general practice

Part C2 - The role of opioids in pain management
    3. A summary of opioid use in chronic non-cancer pain in general practice
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Last revised: 02 Jun 2020

Chronic pain has historically been defined as continuous or recurrent pain that persists for an extended period (generally more than three months). However, the biological mechanisms for chronic pain are quite different from those of acute nociception, and should not be considered as ‘unhealed’ acute pain. Chronic non-cancer pain (CNCP) is a collection of clinical conditions with involvement of single or multiple pathophysiological mechanisms leading to persistent pain. It is also an individual, multifactorial experience influenced by culture, previous pain events, beliefs, expectations, mood and resilience.

Due to methodological weaknesses of chronic pain studies, interpretation and translation of evidence into practice is difficult. There is limited evidence to determine long-term benefits of opioids (outside of end-of-life care); however, there is evidence of risk of harm that increases with dose. While guidelines suggest opioids in the management of some chronic pain conditions, they are not recommended for routine or first-line use.

For accountable prescribing in managing CNCP, GPs should:

  • undertake a complete biopsychosocial assessment of the patient with pain
  • optimise non-drug therapies, and optimise non-opioid therapies as the primary interventions of care.

Opioids for CNCP should be reserved for selected patients with moderate or severe pain that has not responded to other therapies and that significantly affects function or quality of life. If primary interventions fail or are suboptimal, opioid therapies may be considered. GPs should share the decision-making process with the patient, and if opioid therapy is considered, there should be:

  • a patient selection/exclusion process before a therapeutic opioid trial
  • formal care planning based on specific goals and risks
  • an opioid trial, which is undertaken to determine a patient’s response to opioid therapy. This trial includes the selection of an appropriate opioid, formal measures of analgesia and functionality, a trial of dose reduction, and a drug cessation plan if the trial fails
  • an ongoing assessment and evaluation by the accountable prescriber if the trial shows opioid benefit
  • opioid tapering and cessation if suboptimal results or aberrant behaviour occurs.

Long-term use should be uncommon, undertaken with caution and based on consideration of the likely risks and benefits of opioids. Intermittent use is preferable.

GPs should also be aware of chronic pain conditions where there are known clinical complexities involving opioids. These complex clinical areas include the exacerbation of pain or new acute pain in patients on long-term opioid therapy, managing opioids after a non-fatal overdose, and managing the inherited patient.

Some patients on long-term treatment with opioids for CNCP may represent de facto maintenance treatment for iatrogenic opioid dependence. GPs should aim to taper patients taking >100 mg oral morphine equivalent (OME) per day.

  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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