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Clinically Appropriate Treatment Selection

Prescribing Opioids for Pain: When Is it Appropriate?

  • Data from IMS Health National Prescription Audit. Includes 86% of prescriptions captured from a sample of 46,500 pharmacies. Proprietary algorithm used to project a nationally representative sample. 2016 data are estimated.

  • Pezalla EJ, Rosen D, Erensen JG, Haddox JD, Mayne TJ. Secular trends in opioid prescribing in the USA. J Pain Res. 2017; 10(supp): 383-387. PMID: 28243142.

Data indicate that there have been reductions in opioid prescribing since its peak in 2011; however, opioid prescribing still remains high and varies substantially across the United States.1 Some of this prescribing may not always be appropriate. Prescription opioids are associated with a risk for misuse, abuse, and diversion, and treatment guidelines do not recommend opioids as first-line therapy for noncancer chronic pain.2 Instead, treatment guidelines generally recommend that opioids be reserved for patients with moderate to severe pain after inadequate response to nonopioid therapy or when other pharmacotherapies are contraindicated.3-8 Providers are encouraged to first optimize nonopioid therapy, including disease-modifying therapy and nondrug modalities and to continue nonopioid treatment even when opioid therapy has been started for appropriate patients.

On September 10, 2013, the FDA announced labeling changes for all extended-release and longacting opioids, recommending that they be prescribed only for patients with pain severe enough to require daily, around-the-clock, long-term treatment and for whom alternative treatment options are inadequate.9

This section explores the concept of “clinically appropriate treatment selection” by reviewing 3 pathophysiologic types of pain and some considerations for selecting pharmacotherapy based on the type of pain. The goal is to encourage clinicians to reserve opioids for situations in which they are essential.


  1. Pezalla EJ, Rosen D, Erensen JG, Haddox JD, Mayne TJ. Secular trends in opioid prescribing in the USA. J Pain Res. 2017;10:383-387. doi:10.2147/JPR.S129553. eCollection 2017. PMID: 28243142
  2. Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016. MMWR Recomm Rep. 2016;65(No. RR-1):1-49. DOI:
  3. Chou R, Fanciullo GJ, Fine PG, et al; American Pain Society–American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130. PMID: 19187889
  4. US Department of Veterans Affairs, US Department of Defense. VA/DoD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. Version 2.0. Washington, DC: US Dept of Veterans Affairs, US Dept of Defense; 2010. Accessed November 6, 2017.
  5. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Noncancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. Accessed November 6, 2017.
  6. Manchikanti L, Abdi S, Atluri S, et al; American Society of Interventional Pain Physicians. 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-S116. PMID: 22786449
  7. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: Utah Dept of Health; 2009. Accessed November 6, 2017.
  8. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID: 19567713
  9. US Food and Drug Administration. New safety measures announced for extended-release and long-acting opioids: ER/LA opioid analgesic class labeling changes and postmarket requirements [letter to ER/LA opioid application holders]. September 10, 2013. Accessed November 6, 2017.