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Practical Approaches

Practical Approaches to Opioid Prescribing

Universal precautions in opioid prescribing for chronic pain are recommended. As yet, there is no empiric evidence of their effectiveness in reducing the abuse of prescription opioids or the outcomes related to the abuse, misuse, or diversion of prescription opioids.8

Given the well-documented problem of misuse, abuse, and diversion of prescription opioids, health care providers should do more to help encourage appropriate use.10 From a clinical perspective, appropriate use of opioid therapy for patients with chronic pain may be thought of in the framework shown here:

  • First, prescribe opioids only when clinically appropriate.1-6 Current FDA guidance is to prescribe extended-release and long-acting opioids only for patients with pain severe enough to require daily, around-the-clock, long-term treatment, and for whom alternative treatment options are inadequate.11
  • Second, when prescribing opioids for chronic pain, apply universal precautions—a set of uniform practices for prescribers that may help address misuse, abuse, and diversion.1-4,6-8

Although no single intervention will solve the complex problem of prescription opioid abuse, by taking these steps, you as a health care provider may be able to make a real difference.

Follow these links to find out more about clinically appropriate treatment selection and the application of universal precautions. To review these concepts within the context of a clinical setting, explore the accompanying case studies.


  1. 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
  2. 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.
  3. 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.
  4. 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
  5. 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.
  6. Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc. 2009;84(7):593-601. PMID:19567713
  7. 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):107-112. PMID: 15773874
  8. Webster LR, Fine PG. Approaches to improve pain relief while minimizing opioid abuse liability. J Pain. 2010;11(7):602-611. PMID: 20444651
  9. Chou R, Fanciullo GJ, Fine PG, Miaskowski C, Passik SD, Portenoy RK. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):131-146. PMID: 19187890
  10. 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.
  11. 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.