- Screen for opioid abuse to identify opioid abusers.
- Stratify patients based on risk.
- Utilize prescription drug monitoring programs (PDMPs).
- Utilize urine drug testing (UDT).
- Monitor for adherence, abuse, and noncompliance by UDT and PDMPs.

- Establish treatment goals of opioid therapy with regard to pain relief and improvement in function.
- Establish medical necessity based on average moderate to severe (on a scale of 0-10) pain and/or disability.
- Initiate opioid therapy with low dose, short-acting drugs, with appropriate monitoring.
- Avoid long-acting opioids for the initiation of opioid therapy.
- There is similar effectiveness for long-acting and short-acting opioids, with increased adverse consequences of long-acting opioids.
- Recommend long-acting or high-dose opioids only in specific circumstances with severe intractable pain.

- Consider up to 40 morphine milligram equivalent (MME) as low dose, 41-90 MME as a moderate dose, and >91 MME as high dose.
- Periodically assess pain relief and/or functional status improvement of ≥30% without adverse consequences.
- Recommend methadone only for use after failure of other opioid therapy and only by clinicians with specific training in its risks and uses. Periodically monitor patients on methadone with an electrocardiogram.

- Monitor for side effects, including constipation, and manage them appropriately, including discontinuation of opioids when indicated.
- Discontinue opioid therapy for lack of response, adverse consequences, or abuse with rehabilitation.

See reference for more information.

Adapted from Medscape Drugs & Diseases. Key Clinical Practice Guidelines in 2017. Internet. Available at https://reference.medscape.com/viewarticle/890835?src=wnl_drugguide_180122_mscpref&uac=6705FY&impID=1538085&faf=1. Accessed on February 6, 2018. To view the entire article and all other content on the Medscape Drugs & Diseases site, a free, one-time registration is required.