title: Opioids for managing chronic non-malignant pain: safe and effective prescribing.
abstract: OBJECTIVE
  To review the evidence on safe and effective prescribing of opioids for chronic non-malignant pain.
  
  
  METHODS
  MEDLINE was searched using the terms "opioid effectiveness" and "adverse effects." There is strong evidence that opioids are effective for both nociceptive and neuropathic pain, but limited evidence that they are effective for pain disorder. There is little information on their effectiveness at high doses or on the adverse effects of high doses.
  
  
  RESULTS
  Opioids should be initiated after an adequate trial of acetaminophen or nonsteroidal anti-inflammatory drugs for nociceptive pain and of tricyclic antidepressants or anticonvulsants for neuropathic pain. Patients should be asked to sign treatment agreements and to give informed consent to treatment. Patients should experience a graded analgesic response with each dose increase. Titrate doses of immediate-release opioids slowly upward until pain reduction is achieved, and then switch patients to controlled-release opioids. Most patients with chronic non-malignant pain can be managed with<300 mg/d of morphine (or equivalent).
  
  
  CONCLUSIONS
  Opioids are safe and effective for managing chronic pain.
authors.affiliation: Addiction Medical Service, St Joseph's Health Centre, Toronto, Ontario, Canada. kahanm@stjoe.on.ca
authors.forename: Meldon
authors.initials: M
authors.lastname: Kahan
authors.forename: Anita
authors.initials: A
authors.lastname: Srivastava
authors.forename: Lynn
authors.initials: L
authors.lastname: Wilson
authors.forename: Angela
authors.initials: A
authors.lastname: Mailis-Gagnon
authors.forename: Deana
authors.initials: D
authors.lastname: Midmer
mesh_terms: D000701:Analgesics, Opioid / Q000009:adverse effects / Q000627:therapeutic use*; D002170:Canada; D002908:Chronic Disease; D004305:Dose-Response Relationship, Drug; D004334:Drug Administration Schedule; D004363:Drug Utilization; D004502:Education, Medical, Continuing; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009293:Opioid-Related Disorders / Q000453:epidemiology / Q000517:prevention & control*; D010146:Pain / Q000188:drug therapy* / Q000209:etiology / Q000473:pathology*; D010147:Pain Measurement; D015995:Prevalence; D016032:Randomized Controlled Trials as Topic; D018570:Risk Assessment; D012720:Severity of Illness Index
chemical_list: D000701:Analgesics, Opioid