title: [Use of strong opioids in chronic non-cancer pain in adults. Evidence-based recommendations from the French Society for the Study and Treatment of Pain].
abstract: OBJECTIVE
  An urgent need is to improve the efficacy and safety of use of strong opioids in chronic non-cancer pain (CNCP) through responsible prescription rules supported by scientific evidence.
  
  
  METHODS
  Clinical questions addressing the indication, the benefice, the risk and the precautions were formulated. A task force composed of physicians from several medical specialties involved in managing CNCP was charged to elaborate evidence-based recommendations. A systematic literature search was performed using CENTRAL, MEDLINE and EMBASE databases. The approach of the Grading of Recommendations Assessment, Development and Evaluation was applied to evaluate outcomes.
  
  
  RESULTS
  We selected 21 meta-analyses and 31 cohort studies for analysis. Fifteen recommendations are provided. Strong opioids are not recommended in fibromyalgia and primary headaches. Strong opioids have been shown to be moderately effective against CNCP due to osteoarthritis of the lower limbs, and for back pain and neuropathic pain. Their introduction is advised only after the failure of first-line treatments, combined with patient care, provided that the patient is made aware of the advantages and risks. It is not advisable to continue strong opioids treatment for longer than three months if no improvement in pain, function or quality of life is observed. It is also recommended not to prescribe doses exceeding 150mg/day morphine equivalent. Misuse risk factors should be investigated before prescription and misuse should be assessed at each renewal. Priority should be given to extended-release forms. It is recommended not to use transmucosal rapid-release forms of fentanyl for the management of CNCP.
  
  
  CONCLUSIONS
  These recommendations are intended for all doctors needing to prescribe strong opioids in CNCP.
authors.affiliation: CHU Gabriel-Montpied, Clermont université, université d'Auvergne, service de neurologie, Neuro-Dol, Inserm U-1107, 63000 Clermont-Ferrand, France.
authors.forename: Xavier
authors.initials: X
authors.lastname: Moisset
authors.affiliation: CHU de Rouen, service de rhumatologie, 147, avenue du Maréchal-Juin, 76230 Bois-Guillaume, France.
authors.forename: Anne-Priscille
authors.initials: AP
authors.lastname: Trouvin
authors.affiliation: Paris Diderot university, department of general medicine, 16, rue Henri-Huchard, 75018 Paris, France.
authors.forename: Viet-Thi
authors.initials: VT
authors.lastname: Tran
authors.affiliation: CHU, service de pharmacologie, consultation pharmacodépendance, UMR Inserm-1107, BP 69, 63003 Clermont-Ferrand, France.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Authier
authors.affiliation: CHU Dupuytren, université Limoges, service de rhumatologie, 2, avenue Martin-Luther-King, 87042 Limoges, France.
authors.forename: Pascale
authors.initials: P
authors.lastname: Vergne-Salle
authors.affiliation: Centre hospitalier de La Dracénie, centre d'étude et de traitement de la douleur, 83007 Draguignan, France.
authors.forename: Virginie
authors.initials: V
authors.lastname: Piano
authors.affiliation: AP-HP, hôpital Raymond-Poincaré, université de Versailles-St-Quentin, service d'anesthésie réanimation chirurgicale, 104, boulevard Raymond-Poincaré, 92380 Garches, France. Electronic address: valeria.martinez@rpc.aphp.fr.
authors.forename: Valeria
authors.initials: V
authors.lastname: Martinez
mesh_terms: D000328:Adult; D000701:Analgesics, Opioid / Q000627:therapeutic use*; D059350:Chronic Pain / Q000188:drug therapy*; D019317:Evidence-Based Medicine; D006801:Humans; D009369:Neoplasms
chemical_list: D000701:Analgesics, Opioid