Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain
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Interagency Guideline
on Opioid Dosing for
Chronic Non-cancer Pain:
An educational aid to improve
care and safety with opioid therapy
2010 Update
What is New in this Revised Guideline
New data, including scientific evidence to support
the 120mg MED dosing threshold
Tools for calculating dosages of opioids during
treatment and when tapering
Validated screening tools for assessing substance
abuse, mental health, and addiction
Validated two-item scale for tracking function and
pain
Urine drug testing guidance and algorithm
Information on access to mentoring and
consultations (including reimbursement options)
New patient education materials and resources
Guidance on coordinating with emergency
departments to reduce opioid abuse
New clinical tools and resources to help streamline
clinical care
You can find this guideline and related tools at the
Washington State Agency Medical Directors’ site
at www.agencymeddirectors.wa.gov
1Table of Contents
Introduction............................................. 1 Part II: Guidelines for optimizing
treatment when opioid doses are
2010 Update ........................................................1
greater than 120mg MED/day .............. 12
How this guideline is organized ...........................2
Assessing effects of opioid doses greater than
Part I. Guidelines for initiating, 120mg MED/day ............................................... 12
transitioning, and maintaining oral
opioids for chronic non-cancer pain .... 3 How to discontinue opioids or reduce and
reassess at lower doses ................................... 12
Dosing threshold for pain consultation.................3 Referrals to pain centers ................................... 12
BEFORE you decide to prescribe opioids for Recognizing aberrant behaviors during opioid
chronic pain .........................................................4 therapy .............................................................. 12
AFTER you decide with the patient to prescribe Reasons to discontinue opioids or refer for
chronic opioid therapy .........................................5 addiction management...................................... 12
Principles for safely prescribing chronic opioid Referrals for addiction management ................. 13
therapy ................................................................5
Appendices ........................................... 15
Screening and monitoring your patient ................6
Opioid Risk Tool (ORT) ...................................6 Appendix A: Opioid dose calculations ............... 16
CAGE-AID .......................................................6 Appendix B: Screening Tools ............................ 18
PHQ-9 .............................................................6 Appendix C: Tools for Assessing Function and
Tools for assessing function and pain .................6 pain ................................................................... 30
Assessing effects of chronic opioid therapy.........7 Appendix D: Urine Drug Testing for Monitoring
Urine drug testing (UDT) .....................................8 Opioid Therapy ................................................. 31
Methods of testing ...........................................8 Appendix E: Obtaining Consultative Assistance –
Drugs or drug classes to test...........................9 for WA Public Payers Only ................................ 39
Interpreting results...........................................9 Appendix F: Patient Education Resources ........ 41
Specialty consultation ..........................................9 Appendix G: Sample Doctor-Patient Agreements
Unrecognized diagnoses .................................9 for Chronic Opioid Use...................................... 43
Psychological and addiction issues .................9 Appendix H: Additional Resources to Streamline
Opioid management ......................................10 Clinical Care ..................................................... 46
Access to specialists and mentors ....................10 Appendix I: Emergency department guidelines
Tapering or discontinuing opioids ......................10 help coordinate care with primary care providers
.......................................................................... 47
Recognizing and managing behavioral issues
during opioid tapering ........................................11 References ............................................ 48
Acknowledgements.............................. 55Figures and Tables Figure 1. Morphine Equivalent Dose Calculation...........................................................4 Figure 2. Graded Chronic Pain Scale ..................7 Table 1. Guidance For Seeking Consultative Asistance .............................................................4 Table 2. Recommended frequency of UDT .........8 Table 3. Red flag results......................................9 Table 4. Dosing Threshold for Selected Opioids ..............................................................15 Table 5. MED for Selected Opioids ...................16
Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
Introduction released several recommendations for how health
care providers can help. The recommendations
This guideline was originally published in March include:
2007 as an educational pilot. Sponsored by the Use opioid medications for acute or chronic pain
Washington State Agency Medical Directors’ Group only after determining that alternative therapies
(AMDG) 1 , the original guideline and this updated do not deliver adequate pain relief. The lowest
version were developed in collaboration with effective dose of opioids should be used.
actively practicing providers with extensive
experience in the evaluation and treatment of In addition to behavioral screening and use of
patients with chronic pain. It is intended as a patient agreements, consider random, periodic,
resource for primary care providers treating patients targeted urine testing for opioids and other drugs
with chronic noncancer pain. It does not apply to the for any patient less than 65 years old with
treatment of acute pain, cancer pain, or end-of-life noncancer pain who has been treated with
(hospice) care. opioids for more than six weeks.
If a patient’s dosage has increased to 120 mg
Providers prescribing opioids know there is a MED per day or more without substantial
delicate balance between the undertreatment and improvement in function and pain, seek a consult
overtreatment of chronic non-cancer pain. This from a pain specialist.
guideline provides information on the scope of the Do not prescribe long-acting or controlled-
challenge, recommendations for prudent prescribing release opioids (e.g., OxyContin®, fentanyl
and monitoring, advice on how to get consultative patches, and methadone) for acute pain.
assistance, and resources for educating patients.
The full report can be found at
2010 Update www.cdc.gov/HomeandRecreationalSafety/
In 2009, the AMDG surveyed medical providers in Poisoning/brief.htm .
Washington State to assess the acceptability and
usefulness of the guideline and to identify ways to
Data collected in Washington state show:
improve it (available at
http://www.agencymeddirectors.wa.gov/Files/AG During 2004–2007, 1,668 WA residents had
ReportFinal.pdf ). Results of the survey support the confirmed unintentional poisoning deaths due to
continued use of this guideline with the addition of prescription opioid related overdoses6. Nearly
clinical tools and improved information for half of these deaths were in the Medicaid
accessing specialty consultations. population.
Unintentional opioid-related overdose deaths
Recent studies indicate a dramatic increase in increased 17-fold during 1995–2008.
accidental deaths associated with the use of Hospitalizations for opioid-related overdoses
prescription opioids and an increasing average daily increased 7-fold during 1995–2007.
morphine equivalent dose (MED) of the most potent Addiction treatment admissions, where
opioids since 19991-3. Between 1999–2006, people prescription opioids were the primary drug of
aged 35–54 years had higher poisoning death rates abuse, increased from 1.1% to 7.4% between
involving opioid analgesics than those in any other 2000 and 2009.
age group4.
Prescription opioid-related overdose deaths now
exceed non-prescription opioid-related overdose
In response to the increasing morbidity and mortality deaths7.
associated with the increasing use of opioids, the
The death rate from unintentional poisoning
Centers for Disease Control and Prevention5 has
exceeded the death rate from motor vehicle
crashes in 2006, and the gap continues to widen8.
1
The AMDG consists of the medical directors from these
WA State Agencies: Corrections, Social and Health
Services (Medicaid), Labor and Industries, and the Health
Care Authority
1Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
The risks of opioid use are not exclusive to the adult
population. According to the Healthy Youth Survey How this guideline is organized
2008 (available at
The purpose of Part I of the dosing guideline is
http://takeasdirected.doh.wa.gov), Washington
to assist primary care providers in prescribing
teens are using prescription opioid pain medicine to
opioids for adults in a safe and effective
get high. This includes:
manner.
4% of 8th graders
The purpose of Part II is to assist primary care
10 % of 10th graders (21% of these youth providers in treating patients whose morphine
obtained their prescriptions from a dentist or equivalent dose (MED) already exceeds
physician) 120mg/day.
12% of 12th graders
2Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
increase in overdose risk. Most overdoses were
Part I. Guidelines for medically serious, and 12% were fatal.
initiating, transitioning, and High dose opioid therapy can be ineffective and/or
maintaining oral opioids for unsafe. Higher strength pain medicines may be
chronic non-cancer pain associated with poorer functional outcomes than
lower strength opioids11,12. Providers must pay
Part I of the dosing guideline will assist primary care attention to the development of tolerance and
providers in prescribing opioids for adults in a safe adverse outcomes of chronic opioid use13.
and effective manner when:
Instituting or transitioning opioid therapy from This guideline provides a calculator for determining
acute to chronic non-cancer pain; a patient’s daily MED, and a calculator for when the
patient needs an opioid taper plan. For patients
Assessing and monitoring opioid therapy for
already on doses higher than 120mg MED this
chronic non-cancer pain; and
guideline also provides recommendations for
Tapering or discontinuing opioids if an opioid optimizing treatment. Resources for calculating
trial fails to yield improvements in function and MED when patients are on one or more opioids can
pain. An opioid trial is a period of time during be found in Appendix A.
which the effectiveness of using opioids is tested
to see if goals of functionality and decreased In summary, available evidence supports the
pain are met. A trial should occur prior to following recommendations:
treating someone with long-acting opioids and
The total daily dose of opioids should not be
should include goals. If trial goals are not met,
increased above 120mg oral MED without either
the trial should be discontinued and an
the patient demonstrating improvement in
alternative approach taken to treating the pain9.
function and pain or first obtaining a
consultation from a practitioner qualified in
Managing chronic pain and providing appropriate
chronic pain management.
opioid therapy is a challenging aspect of both
primary care and specialty care practices. That is Risks substantially increase at doses at or above
why it is critical for prescribers to be very conscious 100mg,10 so early attention to the 120mg MED
of the risks, and intentional about the treatment plan benchmark dose is worthwhile.
when prescribing these drugs. Best practice Safety and effectiveness of opioid therapy for
treatment requires attention to a number of special chronic non-cancer pain should be routinely
issues. One must balance the need for scientific evaluated by the prescriber.
evidence and skillful clinical decision making in
Assessing the effectiveness of opioid therapy
these very complex cases.
should include tracking and documenting both
functional improvement and pain relief.
Dosing threshold for pain consultation
The hallmark of this guideline is a recommendation If there is evidence of frequent adverse effects or
to not prescribe more than an average daily MED of lack of response to an opioid trial, a specialty
120mg without either the patient demonstrating consultation should be considered. Follow the
improvement in function and pain or first obtaining guidance for seeking consultative assistance as
a consultation from a pain management expert. A described in Table 1.
recent cohort study supports the 120mg MED dosing
threshold. It “provides the first estimates that
directly link receipt of medically prescribed opioids
to overdose risk and suggests that overdose risk is
elevated in chronic non-cancer pain patients
receiving medically prescribed opioids, particularly
in patients receiving higher doses”10. Patients
receiving 100mg or more per day MED had a 9-fold
3Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
Table 1. Guidance For Seeking Consultative Assistance (see page 9 for more details)
Prescribing opioid doses up to 120mg MED/day: Before exceeding 120mg MED/day threshold:
(Cumulative daily dose when using one or more (Cumulative daily dose when using one or more
opioids. See Table 4 in Appendix A for specific opioid opioids. See Table 4 in Appendix A for specific
thresholds.) opioid thresholds.)
No assistance from a pain management consultant No assistance from a pain management
needed if the prescriber is documenting sustained consultant needed if the prescriber is
improvement in both function and pain. documenting sustained improvement in both
Consider getting consultative assistance if frequent function and pain.
adverse effects or lack of response is evident in In general, the total daily dose of opioid should
order to address: not exceed 120 mg oral MED. Risks
- Evidence of undiagnosed conditions; substantially increase at doses at or above
100mg10, so early attention to this benchmark
- Presence of significant psychological condition
dose is worthwhile.
affecting treatment; and
Seek assistance from a pain management
- Potential alternative treatments to reduce or
consultant to address:
discontinue use of opioids.
- Potential alternative treatments to opioids;
- Risk and benefit of a possible trial with
opioid dose above 120mg MED/day;
- Most appropriate way to document
improvement in function and pain; and
- Possible need for consultation from other
specialists
Figure 1. Morphine Equivalent Dose Calculation
For patients taking more than one opioid, the morphine equivalent doses of the different opioids must be
added together to determine the cumulative dose (see Table 5 in Appendix A for MEDs of selected
medications). For example, if a patient takes six hydrocodone 5mg / acetaminophen 500mg and two 20mg
oxycodone extended release tablets per day, the cumulative dose may be calculated as follows:
1) Hydrocodone 5mg x 6 tablets per day = 30mg per day.
2) Using the Equianalgesic Dose table in Appendix A, 30mg Hydrocodone = 30mg morphine equivalents.
3) Oxycodone 20mg x 2 tablets per day = 40mg per day.
4) Per Equianalgesic Dose table, 20mg oxycodone = 30mg morphine so 40mg oxycodone = 60mg
morphine equivalents.
5) Cumulative dose is 30mg + 60mg = 90mg morphine equivalents per day.
An electronic opioid dose calculator can be downloaded at
www.agencymeddirectors.wa.gov/guidelines.asp
4Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
BEFORE you decide to prescribe 3. The PHQ-9 to screen for depression severity
opioids for chronic pain 4. A baseline urine drug test
Acute pain is self-limiting and lasts from a few days 5. A baseline assessment of function and pain
to a few weeks following trauma or surgery. The with the 2 item Graded Chronic Pain Scale
level of pain during an acute phase does not (page 7 and Appendix C)
necessarily and accurately predict the pain level in a
chronic phase. Chronic pain can result from a See “Screening and Monitoring Your Patient” on
number of conditions, diseases or injuries and is Page 6 for more details and see Appendix B for
generally considered as pain lasting more than 3 samples of these screening forms.
months. Because of the potentially serious adverse
long term effects of opioids, it is critical that the
prescriber comprehensively assess the risks and AFTER you decide with the patient to
benefits of treatment prior to deciding whether to prescribe chronic opioid therapy
prescribe opioids. Consider opioid therapy when:
When instituting chronic opioid therapy, both
Other physical, behavioral and non-opioid prescriber and patient should discuss and agree on
measures have failed (e.g. physical therapy, all of the following:
cognitive behavioral therapy, NSAIDs,
Risks and benefits of opioid therapy supported
antidepressants, antiepileptics), and
by an opioid agreement (sample agreements can
The patient has demonstrated sustained be found in Appendix G)
improvement in function and pain levels in
Treatment goals, which must include
previous opioid trial, and
improvements in both function and pain while
The patient has no relative contraindication to monitoring for and minimizing adverse effects
the use of opioids (e.g. current or past alcohol or
Expectation for routine urine drug testing
other substance abuse, including nicotine14,15).
A follow-up plan with specific time intervals to
monitor treatment
Chronic opioid therapy (e.g., more than 90 days of
therapy) should only be initiated on the basis of an Once a decision is made to institute chronic opioid
explicit decision and agreement between prescriber therapy, the prescriber is responsible for routinely
and patient. The patient needs to be informed of the monitoring the safety and effectiveness (improved
benefits and risks of opioid therapy of indefinite function and pain) of ongoing treatment.
duration. Sample agreements for the prescriber and
patient can be found in Appendix G.
Principles for safely prescribing chronic
Screening for potential comorbidities and risk opioid therapy
factors is crucial so that anticipated risk can be
monitored accordingly. Depression and anxiety Single prescriber
disorders are frequently associated with the use of Single pharmacy
opioids16. Current and past substance abuse Patient and prescriber sign opioid agreement
disorders appear to increase the risks of chronic
opioid therapy17-20. If substantial risk is identified Lowest possible effective dose should be used
through screening, extreme caution should be used Be cautious when using opioids with conditions
and a specialty consultation (e.g. addiction or mental that may potentiate opioid adverse effects
health specialist) is strongly encouraged. In such (including COPD, CHF, sleep apnea, current or
cases, a baseline risk assessment using the following past alcohol or substance abuse, elderly, or
tools should be performed and documented in the history of renal or hepatic dysfunction).
record: Do not combine opioids with sedative-hypnotics,
1. The Opioid Risk Tool (ORT) to screen for risk benzodiazepines or barbiturates for chronic non-
of opioid addiction cancer pain unless there is a specific medical
2. The CAGE-AID to screen for alcohol or drug and/or psychiatric indication for the combination
problems
5Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
and increased monitoring is initiated (see Urine CAGE-AID23-25
drug testing, page 8). Purpose: to screen for alcohol or drug problems
Routinely assess function and pain status (see Brief, 4 question-survey
Tools for assessing function and pain, page 6).
Easily accessible
Monitor for medication misuse (for a list of
drug-seeking behaviors, see Reasons to Relatively strong psychometric evidence base
discontinue opioids or refer for addiction
management, page 13). PHQ-926
Random urine drug testing to objectively assure Purpose: to screen for, diagnose, and monitor
compliance (see Urine drug testing, page 8 and depression severity
detailed guidance in Appendix D). Brief, 9-item questionnaire
Easily accessible
Special care should be taken when prescribing Superior psychometric evidence base
methadone for chronic pain. One helpful article for
clinicians is: Methadone Treatment for Pain States21. Additional tools are listed in Appendix B.
Also, free mentoring services are available for
prescribing methadone, using the Physician Clinical
Support System. See Appendix H, "Additional Tools for assessing function and pain
Resources."
The key to effective opioid therapy for chronic non-
cancer pain is to achieve sustained improvement in
pain and physical function27,28. Tracking function
Screening and monitoring your patient
and pain is critical in determining the patient’s
Several screening tools are available to help assess ongoing response to opioids and whether any
risk for aberrant drug-related behavior, current or improvement is consistent with potential changes in
former substance abuse, and mental health disorders. opioid dosing. Critical to this guideline, if function
High risk does not necessarily contraindicate the use and pain do not substantially improve with opioid
of opioids but additional monitoring is indicated dose increases, then significant tolerance to opioids
whenever risk is increased for any reason. may be developing and consultative assistance is
Additional monitoring may include increased strongly recommended.
frequency of reassessment of pain, function, and
aberrant behaviors, decreased number of doses
prescribed, and increased frequency of UDT. Based An assessment of function and pain should
on a review of the literature and the consensus of the consistently measure the same elements to
advisory committee, the following three easy-to-use adequately determine the degree of progress. While
tools are recommended for their clinical utility in there is no universally accepted tool to assess opioid
therapy’s impact on function and pain, several are
screening opioid therapy patients. (The following
available and listed in Appendix C. In particular, the
screening tools are available in Appendix B.)
AMDG recommends using the two item Graded
Chronic Pain Scale29,30 (Figure 2) as an ongoing and
Opioid Risk Tool (ORT)22 rapid method to easily track function and pain in the
Purpose: to assess a patient’s risk of opioid medical record. See Appendix C for instructions on
addiction scoring and interpretation.
Brief, 5-question survey
Easily accessible Other functional assessment tools that may be
Currently, there is no screening tool for risk of
helpful in monitoring your patient’s progress
opioid addiction that has a strong psychometric include, but are not limited to:
evidence base SF36 Health Survey*
www.rand.org/health/surveys_tools/mos/
mos_core_36item.html
Brief Pain Inventory*
6Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
www.ohsu.edu/ahec/pain/paininventory.pdf The prescriber should assess the risks and benefits of
QuickDash* for musculoskeletal disorders of the the patient’s current opioid therapy. This assessment
upper extremities should include:
www.dash.iwh.on.ca/outcome_quick.htm Function and pain status (see Tools for assessing
function and pain, page 6);
Quality of Life Scale*
Possible adverse effects of current opioid doses;
www.uic.edu/orgs/qli/questionaires/
questionnairehome.htm Potential psychiatric disorders affecting
treatment;
Oswestry Disability Index*
Possible drug combinations or conditions that
www.workcover.com/public/download.aspx?i may potentiate opioid adverse effects (such as
d=794&str=disability index oswestry COPD, CHF, sleep apnea, current or past alcohol
Neck Disability Index* or substance abuse, advanced age, or history of
www.workcover.com/public/download.aspx?i renal or hepatic dysfunction); and
d=792&str=disability index neck Any relative contraindication to the use of
Short Musculoskeletal Function Assessment* opioids (active alcohol or other substance abuse,
including nicotine14,15, see Urine drug testing,
See: www.ejbjs.org/cgi/reprint/81/9/1245
page 8).
* These instruments have all been independently
validated and may be available at websites other than If function and pain do not improve after a sufficient
those listed above. opioid trial, consider discontinuing opioids (see
Tapering or Discontinuing Opioids, page 10). When
Assessing effects of chronic opioid there is evidence of significant adverse effects from
therapy opioid therapy, the provider should reduce the opioid
Chronic opioid therapy is associated with the dose and reassess the patient’s status.
development of tolerance to its analgesic effects31,32.
Evidence is accumulating that opioid therapy may Otherwise, if no reasons for dose reduction or
also paradoxically induce abnormal pain sensitivity, discontinuation are identified, and the prescriber
including hyperalgesia and allodynia33-35. Thus, feels (with support of validated measures of function
increasing opioid doses may not improve function and pain) that the patient is benefiting from current
and pain control. therapy, continuation can be appropriate. Ongoing
Figure 2. Graded Chronic Pain Scale
Pain intensity and interference
In the last month, on average, how would you rate your pain? Use a scale from 0 to 10,
where 0 is "no pain" and 10 is "pain as bad as could be"? [That is, your usual pain at times you
were in pain.]
No Pain as bad as
pain could be
0 1 2 3 4 5 6 7 8 9 10
In the last month, how much has pain interfered with your daily activities? Use a scale
from 0 to 10, where 0 is "no interference" and 10 is "unable to carry on any activities"?
No Unable to carry on
interference any activities
0 1 2 3 4 5 6 7 8 9 10
7Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
therapy, however, entails ongoing assessment. The After opioid therapy has been initiated, the
screening described above should be done on a prescriber should randomly repeat testing at the
regular basis to assess progression of therapy as the approximate frequency determined by the patient’s
patient’s condition changes over time. risk category based on the ORT or similar screening
tools (see Table 2).
Urine drug testing (UDT) Although UDT and other screening tools are helpful
The purpose of drug testing is to identify aberrant in identifying aberrant behavior, it is also important
behavior, undisclosed drug use and/or abuse, and for prescribers to use their clinical judgment in the
verify compliance with treatment. When used with development of a monitoring plan. Information from
an appropriate level of understanding, UDT can third parties, such as family and friends, can be
improve the prescriber’s ability to safely and helpful in evaluating behavior. Opioid prescribing
appropriately manage opioid therapy (see Appendix should be avoided in patients with active alcohol or
D – Using Urine Drug Testing to Monitor Opioid other substance abuse. Extreme caution should be
Therapy for Chronic Non-cancer Pain). used, and a consultation with an addiction specialist
is strongly encouraged, prior to prescribing opioids
Urine drug testing is an important part of the for patients with a history of alcohol or other
baseline risk assessment which prescribers should substance abuse.
perform on all candidates for chronic opioid therapy
(see Before you decide to prescribe opioids for Methods of testing
chronic pain, page 5). This baseline UDT should be There is no standard UDT that is suitable for all
performed on all transferring patients who are purposes and settings36. Currently, two main types of
already using opioids and for those patients who you UDT are available:
are considering for chronic opioid therapy (e.g. 3rd Immunoassay drug testing (initial drug test or
opioid prescription or >6 weeks after an acute screen) – based in a lab or office (point-of-care).
injury). Prior to testing, the prescriber should inform
the patient of the reason for testing, the expectation High performance chromatography/mass
of random repeat testing and consequences of spectrometry (confirmatory drug test) – available
unexpected results. This gives the patient an only through a laboratory
opportunity to disclose drug use and allows the
prescriber to modify drug testing for the individual Immunoassays are the most common method of
circumstances and more accurately interpret the testing and can be performed either in a laboratory
results. or at the point-of-care. These tests detect the
presence or absence of a drug or drug class
according to a predetermined cutoff threshold.
Table 2. Recommended Frequency of UDT
Risk Category Recommended UDT Frequency
Low Risk by ORT Periodic
(e.g. up to 1/year)
Moderate Risk by ORT Regular
(e.g. up to 2/year)
High Risk by ORT or opioid doses >120 mg MED/d Frequent
(e.g. up to 3–4/year)
Aberrant Behavior (lost prescriptions, multiple At time of visit
requests for early refill, opioids from multiple
providers, unauthorized dose escalation, apparent (Address aberrant behaviors in person,
intoxication etc.) not by telephone)
8Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
The advantages of immunoassays are their ability to Contact your local laboratory director, toxicologist
concurrently test for multiple drug classes, provide or certified Medical Review Officer (MRO) for
rapid results and guide appropriate utilization of questions about drug testing or results. To locate a
confirmatory testing. However, immunoassays can MRO in your area, submit a search at the following
cross-react with other drugs and vary in sensitivity website: www.aamro.com/registry_search.html. If
and specificity. Thus, unexpected immunoassay a point-of-care device is used, contact technical
results should be interpreted with caution and support from the manufacturer for questions.
verified by confirmatory testing.
Table 3. Red Flag Results
If verification or identification of a specific drug
and/or metabolite(s) is needed, then confirmatory
Negative for opioid(s) you prescribed
testing is recommended. Laboratory-based
confirmation uses gas chromatography/mass Positive for amphetamine or methamphetamine
spectrometry or liquid chromatography/tandem mass Positive for cocaine or metabolites
spectrometry (GC/MS or LC/MS/MS) to identify a Positive for drug (benzodiazepines, opioids, etc)
drug or confirm an immunoassay result. you did not prescribe or have knowledge of
Positive for alcohol
Drugs or drug classes to test
The NIDA 5 (National Institute on Drug Abuse) was
established for workplace drug testing and is
federally regulated. However, it does not test for Specialty consultation
many commonly prescribed or abused drugs such as Specialty consultation is recommended for ongoing
benzodiazepines and semi-synthethic or synthetic severe pain symptoms with no significant
opioids, which may be important in compliance improvement in function despite treatment with
testing. Thus, it may be more useful to order an opioids. Consultation should address possible
expanded urine drug panel to include any of the undiagnosed conditions, psychological conditions
drugs listed below in addition to drugs you are affecting treatment, and alternative treatments. The
prescribing: type of consultation obtained should be determined
Cannabinoids Alcohol by the patient’s presenting signs and symptoms and
Cocaine Barbiturates history. Consultation may be with, but not limited to,
Amphetamines Oxycodone a physician specializing in psychiatry, neurology,
Opiates Methadone anesthesiology, pain, physical medicine and
rehabilitation, orthopedics, addiction medicine,
Benzodiazepines Fentanyl
rheumatology, or oncology.
Interpreting results
Interpreting UDT results can be challenging, Unrecognized diagnoses: In cases of severe
especially when the parent drug can be metabolized ongoing pain symptoms with no improvement in
to other commonly prescribed drugs. When the function despite treatment with opioids, it is
immunoassay result is unexpected and the patient recommended you seek consultative assistance to
does not acknowledge or credibly explain the result, address possible undiagnosed conditions. Examples
a confirmatory test using either GC/MS or include psychiatry, neurology, internal medicine,
LC/MS/MS should be ordered. physical medicine and rehabilitation, orthopedics,
addiction medicine, rheumatology, or oncology.
If the patient tested negative for prescribed opioids
and if confirmatory testing substantiates a “red flag” Psychological and addiction issues: Opioid
result (see Table 3), the prescriber should consider a therapy can be challenging in patients with
controlled taper or stop prescribing opioids symptoms suggestive of mood, anxiety, and
immediately Prescriber may also consider a referral psychotic disorders. Consider psychiatric and/or
to an addiction specialist or drug treatment program psychological consultation for intervention if a
depending on the circumstances. psychological condition is affecting treatment.
Patients with signs of alcohol or other substance
9Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
abuse should be referred to an addiction specialist Access to specialists and mentors
(see Referrals for addiction management, page 13). The names of consultants are available at
www.agencymeddirectors.wa.gov/guidelines.asp.
Opioid management: Consultative assistance for You may also find it helpful to contact one of the
opioid management and prudent prescribing of following organizations that offer credentialing or
opioids should be with a pain management expert certification in pain medicine:
who is familiar with and endorses this guideline. American Board of Pain Medicine
Examples of when to seek assistance include:
American Board of Anesthesiology with
Patients on > 120mg MED/day certification of added qualifications in pain
Questions about methadone treatment management
Tapering patients off opioids American Board of Physical Medicine and
Aberrant behavior Rehabilitation
American Board of Psychiatry and Neurology
Although pain may be relieved at oral morphine
doses up to 120mg MED/day, pain relief is not The University of Washington School of Medicine
necessarily associated with psychological or and its academic medical centers offer a toll free
functional improvement37. Because sustained consultation and referral service available 24 hours
functional improvement is so critical to effective per day 7 days per week. This service helps link you
opioid therapy for chronic non-cancer pain, the with a faculty physician with expertise in any
prescriber should ensure that the patient meets the particular area. To access these services visit, call
following conditions before considering a dosage 800.326.5300, email medcon@washington.edu or
above 120mg MED/day: visit, http://uwmedicine.washington.edu/Patient-
There are no significant psychological issues or Care/Referrals/Pages/MEDCON.aspx.Click on
evidence of drug-seeking behaviors, AND the tab, “Make a Referral” and then the tab
“Expertise” and enter the specialty for which you are
The patient has demonstrated improvement in seeking assistance.
function and pain level previously at a lower
dose.
If these conditions are met, the prescriber may seek a Tapering or discontinuing opioids
pain management consultation or case review to Not all patients benefit from opioids, and a
support possible treatment with opioid doses above prescriber frequently faces the challenge of reducing
120mg MED/day. the opioid dose or discontinuing the opioid
altogether. From a medical standpoint, weaning
Consultation with a specialist does not necessitate from opioids can be done safely by slowly tapering
transfer of the patient for care or ongoing opioid the opioid dose and taking into account the
prescribing. However, the consultant should advise following issues:
the prescribing provider on a pain management plan A decrease by 10% of the original dose per week
and may include: alternative treatments to reduce or is usually well tolerated with minimal
discontinue use of opioids, explanation of the risks physiological adverse effects. Some patients can
and benefits of a possible trial with opioids above be tapered more rapidly without problems (over
120mg/day MED, and the need for ongoing 6 to 8 weeks).
documentation of improvement in function and pain.
If opioid abstinence syndrome is encountered, it
Consultations do not necessarily have to be done is rarely medically serious although symptoms
face to face with the patient. See Appendix E for may be unpleasant.
alternate forms of consultative assistance. Symptoms of an abstinence syndrome, such as
nausea, diarrhea, muscle pain and myoclonus
can be managed with clonidine 0.1 – 0.2 mg
orally every 6 hours or clonidine transdermal
patch 0.1mg/24hrs (Catapres TTS-1™) weekly
during the taper while monitoring often for
10Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
significant hypotension and anticholinergic side Attributing one’s deteriorating psychological
effects. In some patients it may be necessary to state, including suicidal thoughts, to opioid
slow the taper timeline to monthly, rather than withdrawal.
weekly dosage adjustments.
Symptoms of mild opioid withdrawal may There are no fool-proof methods for preventing
persist for six months after opioids have been behavioral issues during an opioid taper, but
discontinued. Rapid reoccurrence of tolerance strategies implemented at the beginning of the
can occur for months to years after prior chronic opioid therapy are most likely to prevent later
use. behavioral problems if an opioid taper becomes
necessary (see AFTER you decide with the patient to
Consider using adjuvant agents, such as
prescribe chronic opioid therapy, page 5). Serious
antidepressants to manage irritability, sleep
suicidal ideation (with plan or intent) should prompt
disturbance or antiepileptics for neuropathic
urgent psychiatric consultation39.
pain.
Do not treat withdrawal symptoms with opioids
or benzodiazepines after discontinuing opioids.
Referral for counseling or other support during
this period is recommended if there are
significant behavioral issues.
Referral to a pain specialist or chemical
dependency center should be made for
complicated withdrawal symptoms.
An Opioid Taper Plan Calculator is available in
Appendix H, Additional Resources.
Recognizing and managing behavioral
issues during opioid tapering
Opioid tapers can be done safely and do not pose
significant health risks to the patient. Special care
needs to be taken by the prescriber to preserve the
therapeutic relationship at this time. Otherwise, taper
can precipitate doctor-shopping, illicit drug use, or
other behaviors that pose a risk to patient safety.
Extremely challenging behavioral issues may
emerge during an opioid taper38.
Behavioral challenges frequently arise when a
prescriber is tapering the opioid dose and a patient
places great value on the opioid he/she is receiving.
In this setting, some patients may feel overwhelmed
or desperate and will try to convince the prescriber
to abandon the opioid taper. Challenges may
include:
Focus on right to pain relief (“You don’t believe
I have real pain”)
Arguments about poor quality of pain care with
threats to complain to administrators or licensing
boards
11Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
Part II: Guidelines for maintain the patient off opioids or at the new
reduced dose and reassess at a later time.
optimizing treatment when
opioid doses are greater than Conversely, if there is evidence of functional and
symptomatic deterioration following opioid taper,
120mg MED/day the prescriber may consider consulting with a pain
Part II of this dosing guideline will assist primary management specialist to evaluate additional
care providers in optimizing treatment: therapeutic options.
When assessing effectiveness of opioid therapy
Referrals to pain centers
in patients who exceed 120mg MED/day;
A referral for counseling or other support during
When reducing the total daily opioid dose; and opioid taper or dose reduction is recommended if
When discontinuing opioid therapy. there are significant behavioral issues. In addition, a
multidisciplinary pain program may be considered
Assessing effects of opioid doses when appropriate to address the psychosocial and
greater than 120mg MED/day cognitive aspects of chronic pain together with
Ongoing opioid therapy requires ongoing assessment patients’ physical rehabilitation41. Early consultative
to optimize therapy. This is important in light of the support may prevent pain from becoming a chronic
evidence that not all patients receive pain relief from disabling condition.
opioids and some develop hyperalgesia and other
abnormal pain sensitivity with chronic high dose
opioid therapy. If, after using the guidelines under Recognizing aberrant behaviors during
Assessing effects of chronic opioid therapy, page 7), opioid therapy
the prescriber feels that current treatment is not Patients who exhibit aberrant behaviors may be at
benefiting the patient, a dose reduction or risk for opioid abuse. There is no universally
discontinuation is warranted. However, if current accepted screening tool to predict aberrant behaviors
treatment is benefiting the patient as demonstrated with opioid therapy for chronic pain. However, it is
by objective measures of function and pain, it may important to identify aberrant behaviors as they can
be appropriate to continue, while establishing a plan affect the medical management of your patients and
to monitor therapy as the patient’s condition changes help predict misue of opioids (see Reasons to
over time (see Principles for safely prescribing discontinue opioids or refer for addiction
chronic opioid therapy, page 5). management, page 13)42.
Patients with a comorbid psychiatric condition or
How to discontinue opioids or reduce addiction are at higher risk of opioid misuse despite
and reassess at lower doses their attempts to follow the treatment plan38,43,44.
Treatment with opioids, even at high doses, will not Prescribers should intensify monitoring and scrutiny
eliminate all chronic pain, and some patients may do and seek a consultation with an addiction specialist
better on lower doses of opioids13,34,40. A decrease by if there is past or active substance dependence or
10% of the original dose per week is usually well abuse.
tolerated. An Opioid Taper Plan Calculator is
available in Appendix H, Additional Resources.
Behavioral issues or physical withdrawal symptoms
can be a major obstacle to an otherwise beneficial
dose reduction (see Tapering or discontinuing
opioids, page 10, and Recognizing and managing
behavioral issues during opioid tapering, page 11).
The prescriber should assess the patient’s status
periodically during the tapering process. If the
chosen assessment tool indicates improved patient
status other than subjective pain complaints, or if
there is improvement in opioid-related side effects,
12Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
Reasons to discontinue opioids or refer Referrals for addiction management
for addiction management A patient who exhibits overt signs of alcohol or
No improvement in function and pain or substance use disorder should be referred to an
addiction specialist for appropriate treatment.
Opioid therapy produces significant adverse Prognosis is poor for patients with a Diagnostic and
effects or
Statistical Manual of Mental Disorders (DSM)
Patient exhibits drug-seeking behaviors or diagnosis of opioid dependence or opioid abuse who
diversion such as: do not receive treatment45,46.
- Selling prescription drugs
- Forging prescriptions
- Stealing or borrowing drugs
- Frequently losing prescriptions
- Aggressive demand for opioids
- Injecting oral/topical opioids
- Unsanctioned use of opioids
- Unsanctioned dose escalation
- Concurrent use of illicit drugs
- Failing a drug screen
- Getting opioids from multiple prescribers
- Recurring emergency department visits for
chronic pain management (see section on
Emergency Department Guidelines in
Appendix H, Additional Resources).
13Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
14Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain (CNCP)
Appendices
Appendix A: Opioid Dose Calculations
Appendix B: Screening Tools
Appendix C: Tools for Assessing Function and Pain
Appendix D: Urine Drug Testing for Monitoring Opioid Therapy
Appendix E: Quick Reference for Obtaining Consultative Assistance –
for Washington Public Payers Only
Appendix F: Patient Education Resources
Appendix G: Sample Doctor-Patient Agreements for Chronic Opioid Use
Appendix H: Additional Resources to Streamline Clinical Care
Appendix I: Emergency department guidelines help coordinate care with
primary care providers
15Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain
Appendix A: Opioid dose calculations
Table 4. Dosing Threshold for Selected Opioids*
Recommended Recommended
dose threshold for starting dose for
pain consult (not opioid-naïve
Opioid equianalgesic) patients Considerations
See individual product labeling for maximum dosing
of combination products. Avoid concurrent use of
Codeine 800mg per 24 hours 30mg q 4–6 hours
any OTC products containing same ingredient.
See acetaminophen warning, below.
Fentanyl Use only in opioid-tolerant patients who have been
50mcg/hour (q 72 hr)
Transdermal taking ≥ 60mg MED daily for a week or longer
See individual product labeling for maximum
dosing of combination products. Avoid concurrent
Hydrocodone 120mg per 24 hours 5-10mg q 4–6 hours
use of any OTC products containing same
ingredient. See acetaminophen warning, below.
Hydromorphone 30mg per 24 hours 2mg q 4–6 hours
Methadone is difficult to titrate due to its half-life
variability. It may take a long time to reach a stable
level in the body. Methadone dose should not be
Methadone 40mg per 24 hours 2.5-5mg BID – TID
increased more frequently than every 7 days. Do
not use as PRN or combine with other long-acting
(LA) opioids.
Immediate-release: Adjust dose for renal impairment.
10mg q 4 hours
Morphine 120mg per 24 hours
Sustained-release:
15mg q 12 hours
Immediate-release: See individual product labeling for maximum
dosing of combination products. Avoid concurrent
5mg q 4–6 hours
use of any OTC products containing same
Oxycodone 80mg per 24 hours
ingredient. See acetaminophen warning, below.
Sustained Release:
10mg q 12 hours
Immediate-release: Use with extreme caution due to potential fatal
interaction with alcohol or medications
5–10mg q 4–6 hours
containing alcohol.
Oxymorphone 40mg per 24 hours
Sustained Release:
10mg q 12 hours
*Meperidine and propoxyphene products should not be prescribed for chronic non-cancer pain.
16Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain Acetaminophen warning with combination products Hepatotoxicity can result from prolonged use or doses in excess of recommended maximum total daily dose of acetaminophen including over-the-counter products. Short-term use (
Appendix B: Screening Tools
Based on a review of the literature and the consensus of the advisory committee, the first three highlighted tools are recommended for their clinical
utility in screening opioid therapy patients.
To Screen For To Monitor Tool Characteristics
Depression,
Risk of Current/Past Available for
Mental/ Opioid Time to Length
Opioid Substance Administration Public Use
Behavioral Therapy Complete
Addiction Abuse (Cost)
Health
Clinician or
Opioid Risk Tool (ORT) 5 (yes/no)
X patient self- 5 minutes X (Free)
See Page 19. questions
report
CAGE Adapted to Include
4 (yes/no)
Drugs (CAGE-AID) X Clinician < 5 minutes X (Free)
questions
See Page 20.
Patient Health Questionnaire
Patient self-
9 (PHQ-9) X < 5 minutes 10 items X (Free)
report
See Page 21.
Screener and Opioid
X (Free, with
Assessment for Patients with Patient self-
X < 10 minutes 24 items licensing
Pain (SOAPP-R) report
agreement)
www.painedu.org/soapp.asp
Alcohol Use Disorders Clinician or
10 items
Identification Test (AUDIT) X patient self- < 5 minutes X (Free)
See Page 24. report
Center for Epidemiologic
Studies Depression Scale Patient self-
X 5 minutes 20 items X (Free)
(CES-D) report
See Page 26.
Global Appraisal of
Individual Needs Short Staff or patient 15 (yes/no)
X 5 minutes X (Free)
Screener (GAIN-SS) self-report questions
See Page 29.
Current Opioid Misuse X (Free, with
Patient self-
Measure (COMM) X < 10 minutes 17 items licensing
report
www.painedu.org/soapp.asp agreement)
*The tools listed in this table have demonstrated good content, face, and construct validity in screening for risk of addiction and monitoring opioid therapy. Further validation studies and
prospective outcome studies are needed to determine how the use of these tools predicts and affects clinical outcomes.
18Date _____________________________
Patient Name ________________________________
OPIOID RISK TOOL
Mark each Item Score Item Score
box that applies If Female If Male
1. Family History of Substance Abuse Alcohol [ ] 1 3
Illegal Drugs [ ] 2 3
Prescription Drugs [ ] 4 4
2. Personal History of Substance Abuse Alcohol [ ] 3 3
Illegal Drugs [ ] 4 4
Prescription Drugs [ ] 5 5
3. Age (Mark box if 16 – 45) [ ] 1 1
4. History of Preadolescent Sexual Abuse [ ] 3 0
5. Psychological Disease Attention Deficit
Disorder [ ] 2 2
Obsessive Compulsive
Disorder
Bipolar
Schizophrenia
Depression [ ] 1 1
TOTAL [ ]
Total Score Risk Category Low Risk 0 – 3 Moderate Risk 4 – 7 High Risk > 8
19CAGE-AID Questionnaire
Patient Name __________________________________ Date of Visit ___________________
When thinking about drug use, include illegal drug use and the use of prescription drug other
than prescribed.
Questions: YES NO_______
1. Have you ever felt that you ought to cut down on your drinking
or drug use?
…………………………………………………………………………………………………....
2. Have people annoyed you by criticizing your drinking or drug use?
……………………………………………………………………………………………............
3. Have you ever felt bad or guilty about your drinking or drug use?
……………………………………………………………………………………………............
4. Have you ever had a drink or used drugs first thing in the morning
to steady your nerves or to get rid of a hangover?________________________________
Scoring
Regard one or more positive responses to the CAGE-AID as a positive screen.
Psychometric Properties
The CAGE-AID exhibited: Sensitivity Specificity
One or more Yes responses 0.79 0.77
Two or more Yes responses 0.70 0.85
(Brown 1995)
20PHQ-9 — Nine Symptom Checklist
Patient Name Date
1. Over the last 2 weeks, how often have you been bothered by any of the following
problems? Read each item carefully, and circle your response.
a. Little interest or pleasure in doing things
Not at all Several days More than half the days Nearly every day
b. Feeling down, depressed, or hopeless
Not at all Several days More than half the days Nearly every day
c. Trouble falling asleep, staying asleep, or sleeping too much
Not at all Several days More than half the days Nearly every day
d. Feeling tired or having little energy
Not at all Several days More than half the days Nearly every day
e. Poor appetite or overeating
Not at all Several days More than half the days Nearly every day
f. Feeling bad about yourself, feeling that you are a failure, or feeling that you have
let yourself or your family down
Not at all Several days More than half the days Nearly every day
g. Trouble concentrating on things such as reading the newspaper or watching
television
Not at all Several days More than half the days Nearly every day
h. Moving or speaking so slowly that other people could have noticed. Or being so
fidgety or restless that you have been moving around a lot more than usual
Not at all Several days More than half the days Nearly every day
i. Thinking that you would be better off dead or that you want to hurt yourself in
some way
Not at all Several days More than half the days Nearly every day
2. If you checked off any problem on this questionnaire so far, how difficult have these
problems made it for you to do your work, take care of things at home, or get along
with other people?
Not Difficult at All Somewhat Difficult Very Difficult Extremely Difficult
Copyright held by Pfizer Inc, but may be photocopied ad libitum
1 Tools May be printed without permission
21PHQ-9 — Scoring Tally Sheet
Patient Name Date
1. Over the last 2 weeks, how often have you been bothered by any of the
following problems? Read each item carefully, and circle your response.
Not Several More than Nearly
at all days half the days every day
0 1 2 3
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling asleep, staying asleep, or
sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself, feeling that you are
a failure, or feeling that you have let yourself
or your family down
g. Trouble concentrating on things such as
reading the newspaper or watching television
h. Moving or speaking so slowly that other
people could have noticed. Or being so fidgety
or restless that you have been moving around a
lot more than usual
i. Thinking that you would be better off dead or
that you want to hurt yourself in some way
Totals
2. If you checked off any problem on this questionnaire so far, how difficult
have these problems made it for you to do your work, take care of things at
home, or get along with other people?
Not Difficult At All Somewhat Difficult Very Difficult Extremely Difficult
0 1 2 3
Copyright held by Pfizer Inc, but may be photocopied ad libitum
2 Tools May be printed without permission
22How to Score PHQ-9
Scoring Method Major Depressive Syndrome is suggested if:
For Diagnosis • Of the 9 items, 5 or more are circled as at least "More than half the days"
• Either item 1a or 1b is positive, that is, at least "More than half
the days"
Minor Depressive Syndrome is suggested if:
• Of the 9 items, b, c, or d are circled as at least "More than half the
days"
• Either item 1a or 1b is positive, that is, at least "More than half
the days"
Scoring Method Question One
For Planning • To score the first question, tally each response by the number
And Monitoring
value of each response:
Treatment
Not at all = 0
Several days = 1
More than half the days = 2
Nearly every day = 3
• Add the numbers together to total the score.
• Interpret the score by using the guide listed below:
Score Action
5-14 Physician uses clinical judgment about treatment, based on
patient’s duration of symptoms and functional impairment.
>15 Warrants treatment for depression, using antidepressant,
psychotherapy and/or a combination of treatment
Question Two
In question two the patient responses can be one of four: not
difficult at all, somewhat difficult, very difficult, extremely difficult.
The last two responses suggest that the patient's functionality is
impaired. After treatment begins, the functional status is again
measured to see if the patient is improving.
Copyright held by Pfizer Inc, but may be photocopied ad libitum
3 Tools How to Score PHQ-9
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