Korean J Pain.  2024 Apr;37(2):119-131. 10.3344/kjp.24022.

Updated guidelines for prescribing opioids to treat patients with chronic non-cancer pain in Korea: developed by committee on hospice and palliative care of the Korean Pain Society

• Kim M
• Park SK
• Kim WM
• Kim E
• Kim H
• Park JM
• Choi SS
• Choi EJ

• KMID: 2554952
• DOI: http://doi.org/10.3344/kjp.24022

Abstract

There are growing concerns regarding the safety of long-term treatment with opioids of patients with chronic noncancer pain. In 2017, the Korean Pain Society (KPS) developed guidelines for opioid prescriptions for chronic non-cancer pain to guide physicians to prescribe opioids effectively and safely. Since then, investigations have provided updated data regarding opioid therapy for chronic non-cancer pain and have focused on initial dosing schedules, reassessment follow-ups, recommended dosage thresholds considering the risk-benefit ratio, dosereducing schedules for tapering and discontinuation, adverse effects, and inadvertent problems resulting from inappropriate application of the previous guidelines. Herein, we have updated the previous KPS guidelines based on a comprehensive literature review and consensus development following discussions among experts affiliated with the Committee on Hospice and Palliative Care in the KPS. These guidelines may assist physicians in prescribing opioids for chronic non-cancer pain in adult outpatient settings, but should not to be regarded as an inflexible standard. Clinical judgements by the attending physician and patient-centered decisions should always be prioritized.

Keyword

Adult; Analgesics; Chronic Pain; Drug Monitoring; Drug Prescriptions; Opioid-Related Disorders; Prescription Drug Misuse; Treatment Outcome

Reference

1. Manchikanti L, Kaye AM, Knezevic NN, McAnally H, Slavin K, Trescot AM, et al. 2017; Responsible, safe, and effective prescription of opioids for chronic non-cancer pain: American Society of Interventional Pain Physicians (ASIPP) guidelines. Pain Physician. 20:S3–92. DOI: 10.36076/ppj.2017.s92.

2. Häuser W, Morlion B, Vowles KE, Bannister K, Buchser E, Casale R, et al. 2021; European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: role of opioids in the management of chronic noncancer pain. Eur J Pain. 25:949–68. DOI: 10.1002/ejp.1736. PMID: 33655607. PMCID: PMC8248186.

3. Oh TK, Jeon YT, Choi JW. 2019; Trends in chronic opioid use and association with five-year survival in South Korea: a population-based cohort study. Br J Anaesth. 123:655–63. DOI: 10.1016/j.bja.2019.08.012. PMID: 31558315.

4. Noh Y, Heo KN, Yu YM, Lee JY, Ah YM. 2022; Trends in potentially inappropriate opioid prescribing and associated risk factors among Korean noncancer patients prescribed non-injectable opioid analgesics. Ther Adv Drug Saf. 13:20420986221091001. DOI: 10.1177/20420986221091001. PMID: 35509350. PMCID: PMC9058459.

5. Porter J, Jick H. 1980; Addiction rare in patients treated with narcotics. N Engl J Med. 302:123. DOI: 10.1056/NEJM198001103020221. PMID: 7350425.

6. Rummans TA, Burton MC, Dawson NL. 2018; How good intentions contributed to bad outcomes: the opioid crisis. Mayo Clin Proc. 93:344–50. DOI: 10.1016/j.mayocp.2017.12.020. PMID: 29502564.

7. Yang J, Bauer BA, Wahner-Roedler DL, Chon TY, Xiao L. 2020; The modified WHO analgesic ladder: is it appropriate for chronic non-cancer pain? J Pain Res. 13:411–7. DOI: 10.2147/JPR.S244173. PMID: 32110089. PMCID: PMC7038776.

8. Kim ED, Lee JY, Son JS, Byeon GJ, Yeo JS, Kim DW, et al. Opioids Research Group in the Korean Pain Society. 2017; Guidelines for prescribing opioids for chronic non-cancer pain in Korea. Korean J Pain. 30:18–33. DOI: 10.3344/kjp.2017.30.1.18. PMID: 28119768. PMCID: PMC5256264.

9. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. DOI: 10.15585/mmwr.rr7103a1. PMID: 36327391. PMCID: PMC9639433.

10. Turk DC, Robinson JP. Ballantyne JC, Fishman SM, Rathmell JP, editors. 2019. Multidisciplinary assessment of patients with chronic pain. In: Bonica's management of pain. 5th ed. Wolters Kluwer;p. 313–24.

11. Kim S, Kim E, Suh HS. 2021; Cost-effectiveness of an opioid abuse-prevention program using the narcotics information management system in South Korea. Value Health. 24:174–81. DOI: 10.1016/j.jval.2020.12.002. PMID: 33518023.

12. Lee J, Noh Y, Lee S. 2018; Evaluation of preventable adverse drug reactions by implementation of the nationwide network of prospective drug utilization review program in Korea. PLoS One. 13:e0195434. DOI: 10.1371/journal.pone.0195434. PMID: 29641617. PMCID: PMC5895028.

13. Busse JW, Sadeghirad B, Oparin Y, Chen E, Goshua A, May C, et al. 2020; Management of acute pain from non-low back, musculoskeletal injuries: a systematic review and network meta-analysis of randomized trials. Ann Intern Med. 173:730–8. DOI: 10.7326/M19-3601. PMID: 32805127.

14. Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, et al. 2018; Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA. 319:872–82. DOI: 10.1001/jama.2018.0899. PMID: 29509867. PMCID: PMC5885909.

15. 2020. Sep. 22. Neuropathic pain in adults: pharmacological management in non-specialist settings [Internet]. National Institute for Health and Care Excellence (NICE);London: (NICE Clinical Guidelines, No. 173.) Available at: https://www.ncbi.nlm.nih.gov/books/NBK552848/.

16. Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. 2017; Guideline for opioid therapy and chronic noncancer pain. CMAJ. 189:E659–66. DOI: 10.1503/cmaj.170363. PMID: 28483845. PMCID: PMC5422149.

17. Chou R, Hartung D, Turner J, Blazina I, Chan B, Levander X, et al. 2020. Apr. Opioid treatments for chronic pain [Internet]. Agency for Healthcare Research and Quality (US);Rockville (MD): (Comparative Effectiveness Review, No. 229.) Available at: https://www.ncbi.nlm.nih.gov/books/NBK556253/. DOI: 10.23970/AHRQEPCCER229.

18. Miller M, Barber CW, Leatherman S, Fonda J, Hermos JA, Cho K, et al. 2015; Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy. JAMA Intern Med. 175:608–15. DOI: 10.1001/jamainternmed.2014.8071. PMID: 25686208.

19. Krčevski Škvarč N, Morlion B, Vowles KE, Bannister K, Buchsner E, Casale R, et al. 2021; European clinical practice recommendations on opioids for chronic noncancer pain - Part 2: special situations. Eur J Pain. 25:969–85. DOI: 10.1002/ejp.1744. PMID: 33655678.

20. Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, et al. 2014; The effectiveness and risks of long-term opioid treatment of chronic pain. Evid Rep Technol Assess (Full Rep). 218:1–219. DOI: 10.23970/AHRQEPCERTA218. PMID: 30313000.

21. Moisset X, Martinez V. 2016; Opioid use for the management of chronic non-cancer pain: French guidelines. Rev Neurol (Paris). 172:337–8. DOI: 10.1016/j.neurol.2016.05.004. PMID: 27342007.

22. Kalso E, Simpson KH, Slappendel R, Dejonckheere J, Richarz U. 2007; Predicting long-term response to strong opioids in patients with low back pain: findings from a randomized, controlled trial of transdermal fentanyl and morphine. BMC Med. 5:39. DOI: 10.1186/1741-7015-5-39. PMID: 18154644. PMCID: PMC2242794.

23. Hasin DS, O'Brien CP, Auriacombe M, Borges G, Bucholz K, Budney A, et al. 2013; DSM-5 criteria for substance use disorders: recommendations and rationale. Am J Psychiatry. 170:834–51. DOI: 10.1176/appi.ajp.2013.12060782. PMID: 23903334. PMCID: PMC3767415.

24. O'Brien CP, Volkow N, Li TK. 2006; What's in a word? Addiction versus dependence in DSM-V. Am J Psychiatry. 163:764–5. DOI: 10.1176/ajp.2006.163.5.764. PMID: 16648309.

25. National Conference of State Legislatures. 2020. Prescribing policies: states confront opioid overdose epidemic [Internet]. National Conference of State Legislatures. Available at: https://www.ncsl.org/research/health/prescribing-policies-states-confront-opioid-overdose-epidemic.

26. Shah A, Hayes CJ, Martin BC. DOI: 10.15585/mmwr.mm6610a1. PMID: 28301454. PMCID: PMC5657867.

27. Brummett CM, Waljee JF, Goesling J, Moser S, Lin P, Englesbe MJ, et al. 2017; New persistent opioid use after minor and major surgical procedures in US adults. JAMA Surg. 152:e170504. Erratum in: JAMA Surg 2019; 154: 272. DOI: 10.1001/jamasurg.2017.0504. PMID: 28403427. PMCID: PMC7050825.

28. Mundkur ML, Franklin JM, Abdia Y, Huybrechts KF, Patorno E, Gagne JJ, et al. 2019; Days' supply of initial opioid analgesic prescriptions and additional fills for acute pain conditions treated in the primary care setting - United States, 2014. MMWR Morb Mortal Wkly Rep. 68:140–3. DOI: 10.15585/mmwr.mm6806a3. PMID: 30763301. PMCID: PMC6375655.

29. Chou R, Wagner J, Ahmed AY, Blazina I, Brodt E, Buckley DI, et al. 2020. Dec. Treatments for acute pain: a systematic review [Internet]. Treatments for acute pain: a systematic review [Internet]. Agency for Healthcare Research and Quality (US);Rockville (MD): Report No.: 20(21)-EHC006. DOI: 10.23970/AHRQEPCCER240.

30. Edlund MJ, Martin BC, Russo JE, DeVries A, Braden JB, Sullivan MD. 2014; The role of opioid prescription in incident opioid abuse and dependence among individuals with chronic noncancer pain: the role of opioid prescription. Clin J Pain. 30:557–64. DOI: 10.1097/AJP.0000000000000021. PMID: 24281273. PMCID: PMC4032801.

31. Oliva EM, Bowe T, Manhapra A, Kertesz S, Hah JM, Henderson P, et al. 2020; Associations between stopping prescriptions for opioids, length of opioid treatment, and overdose or suicide deaths in US veterans: observational evaluation. BMJ. 368:m283. DOI: 10.1136/bmj.m283. PMID: 32131996. PMCID: PMC7249243.

32. Rich RC, Chou R, Mariano ER, Dopp AL, Sullenger R, Burstin H. Pain Management Guidelines and Evidence Standards Working Group. 2020; Best practices, research gaps, and future priorities to support tapering patients on long-term opioid therapy for chronic non-cancer pain in outpatient settings. NAM Perspect 2020. 10.31478/202008c. DOI: 10.31478/202008c. PMID: 35291734. PMCID: PMC8916797.

33. U.S. Food and Drug Administration. 2019. Safety Announcement. FDA identifies harm reported from sudden discontinuation of opioid pain medicines and requires label changes to guide prescribers on gradual, individualized tapering [Internet]. U.S. Food and Drug Administration;Available at: https://www.fda.gov/Drugs/DrugSafety/ucm635038.htm.

34. Mark TL, Parish W. 2019; Opioid medication discontinuation and risk of adverse opioid-related health care events. J Subst Abuse Treat. 103:58–63. DOI: 10.1016/j.jsat.2019.05.001. PMID: 31079950.

35. Dowell D, Compton WM, Giroir BP. 2019; Patient-centered reduction or discontinuation of long-term opioid analgesics: the HHS guide for clinicians. JAMA. 322:1855–6. DOI: 10.1001/jama.2019.16409. PMID: 31600366. PMCID: PMC7145754.

36. Joo SS, Hunter OO, Tamboli M, Leng JC, Harrison TK, Kassab K, et al. 2020; Implementation of a patient-specific tapering protocol at discharge decreases total opioid dose prescribed for 6 weeks after elective primary spine surgery. Reg Anesth Pain Med. 45:474–8. DOI: 10.1136/rapm-2020-101324. PMID: 32238478.

37. Tamboli M, Mariano ER, Gustafson KE, Briones BL, Hunter OO, Wang RR, et al. 2020; A multidisciplinary patient-specific opioid prescribing and tapering protocol is associated with a decrease in total opioid dose prescribed for six weeks after total hip arthroplasty. Pain Med. 21:1474–81. DOI: 10.1093/pm/pnz260. PMID: 31710680.

38. Swarm RA, Paice JA, Anghelescu DL, Are M, Bruce JY, Buga S, et al. 2019; Adult cancer pain, version 3.2019, NCCN clinical practice guidelines in oncology. J Natl Compr Canc Netw. 17:977–1007. DOI: 10.6004/jnccn.2019.0038. PMID: 31390582.

39. Nielsen S, Degenhardt L, Hoban B, Gisev N. 2016; A synthesis of oral morphine equivalents (OME) for opioid utilisation studies. Pharmacoepidemiol Drug Saf. 25:733–7. DOI: 10.1002/pds.3945. PMID: 26693665.

40. Voon P, Karamouzian M, Kerr T. 2017; Chronic pain and opioid misuse: a review of reviews. Subst Abuse Treat Prev Policy. 12:36. DOI: 10.1186/s13011-017-0120-7. PMID: 28810899. PMCID: PMC5558770.

41. Savage SR, Joranson DE, Covington EC, Schnoll SH, Heit HA, Gilson AM. 2003; Definitions related to the medical use of opioids: evolution towards universal agreement. J Pain Symptom Manage. 26:655–67. DOI: 10.1016/S0885-3924(03)00219-7. PMID: 12850648.

42. Kosten TR, Rounsaville BJ, Babor TF, Spitzer RL, Williams JB. 1987; Substance-use disorders in DSM-III-R. Evidence for the dependence syndrome across different psychoactive substances. Br J Psychiatry. 151:834–43. DOI: 10.1192/bjp.151.6.834. PMID: 2901887.

43. Fainsinger RL, Thai V, Frank G, Fergusson J. 2006; What's in a word? Addiction versus dependence in DSM-V. Am J Psychiatry. 163:2014. DOI: 10.1176/ajp.2006.163.11.2014a. PMID: 17074958.

44. Miller SC. 2006; Language and addiction. Am J Psychiatry. 163:2015. DOI: 10.1176/ajp.2006.163.11.2015. PMID: 17074960.

45. Streltzer J, Sullivan CR, Johnson B. 2006; Addiction versus dependence in pain management. Am J Psychiatry. 163:2016. DOI: 10.1176/ajp.2006.163.11.2016. PMID: 17074961.

46. O'Brien C. 2011; Addiction and dependence in DSM-V. Addiction. 106:866–7. DOI: 10.1111/j.1360-0443.2010.03144.x. PMID: 21477226. PMCID: PMC3812919.

47. Ballantyne JC. 2015; Assessing the prevalence of opioid misuse, abuse, and addiction in chronic pain. Pain. 156:567–8. DOI: 10.1097/j.pain.0000000000000105. PMID: 25630030.

48. Ballantyne JC, Sullivan MD, Kolodny A. 2012; Opioid dependence vs addiction: a distinction without a difference? Arch Intern Med. 172:1342–3. DOI: 10.1001/archinternmed.2012.3212. PMID: 22892799.

49. Kosten TR, Baxter LE. 2019; Review article: effective management of opioid withdrawal symptoms: a gateway to opioid dependence treatment. Am J Addict. 28:55–62. DOI: 10.1111/ajad.12862. PMID: 30701615. PMCID: PMC6590307.