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Clinically Appropriate Treatment Selection

Prescribing Opioids for Pain: When Is it Appropriate?

Data suggest that opioids increasingly are being prescribed to address the needs of patients with pain.1 However, some of this prescribing may not always be appropriate. Because prescription opioids are associated with a risk for misuse, abuse, and diversion, treatment guidelines generally recommend that they be reserved for patients with moderate to severe pain after inadequate response to nonopioid therapy or when other pharmacotherapies are contraindicated.2-7

On September 10, 2013, the FDA announced labeling changes for all extended-release and long-acting 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.8

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. Centers for Disease Control and Prevention. Primary Care and Public Health Initiative. Prescription Drug Abuse and Overdose: Public Health Perspective. October 24, 2012. Accessed May 20, 2014.
  2. 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
  3. 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 May 20, 2014.
  4. Washington State Agency Medical Directors’ Group (AMDG). Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain: An Educational Aid to Improve Care and Safety With Opioid Therapy. 2010 Update. Olympia, WA: Washington State Agency Medical Directors Group; 2010. Accessed May 20, 2014.
  5. 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
  6. Utah Department of Health. Utah Clinical Guidelines on Prescribing Opioids for Treatment of Pain. Salt Lake City, UT: Utah Dept of Health; 2009. Accessed May 20, 2014.
  7. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID: 19567713
  8. 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 May 20, 2014.