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. 2021 May;25(5):949-968.
doi: 10.1002/ejp.1736. Epub 2021 Mar 2.

European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain

Winfried Häuser  1   2 , Bart Morlion  3 , Kevin E Vowles  4 , Kirsty Bannister  5 , Eric Buchser  6 , Roberto Casale  7 , Jean-François Chenot  8 , Gillian Chumbley  9 , Asbjørn Mohr Drewes  10 , Geert Dom  11 , Liisa Jutila  12 , Tony O'Brien  13 , Esther Pogatzki-Zahn  14 , Martin Rakusa  15 , Carmen Suarez-Serrano  16 , Thomas Tölle  17 , Nevenka Krčevski Škvarč  18
Affiliations

European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain

Winfried Häuser et al. Eur J Pain. 2021 May.

Abstract

Background: Opioid use for chronic non-cancer pain (CNCP) is complex. In the absence of pan-European guidance on this issue, a position paper was commissioned by the European Pain Federation (EFIC).

Methods: The clinical practice recommendations were developed by eight scientific societies and one patient self-help organization under the coordination of EFIC. A systematic literature search in MEDLINE (up until January 2020) was performed. Two categories of guidance are given: Evidence-based recommendations (supported by evidence from systematic reviews of randomized controlled trials or of observational studies) and Good Clinical Practice (GCP) statements (supported either by indirect evidence or by case-series, case-control studies and clinical experience). The GRADE system was applied to move from evidence to recommendations. The recommendations and GCP statements were developed by a multiprofessional task force (including nursing, service users, physicians, physiotherapy and psychology) and formal multistep procedures to reach a set of consensus recommendations. The clinical practice recommendations were reviewed by five external reviewers from North America and Europe and were also posted for public comment.

Results: The key clinical practice recommendations suggest: (a) first optimizing established non-pharmacological treatments and non-opioid analgesics and (b) considering opioid treatment if established non-pharmacological treatments or non-opioid analgesics are not effective and/or not tolerated and/or contraindicated. Evidence- and clinical consensus-based potential indications and contraindications for opioid treatment are presented. Eighteen GCP recommendations give guidance regarding clinical evaluation, as well as opioid treatment assessment, monitoring, continuation and discontinuation.

Conclusions: Opioids remain a treatment option for some selected patients with CNCP under careful surveillance.

Significance: In chronic pain, opioids are neither a universal cure nor a universally dangerous weapon. They should only be used for some selected chronic noncancer pain syndromes if established non-pharmacological and pharmacological treatment options have failed in supervised pain patients as part of a comprehensive, multi-modal, multi-disciplinary approach to treatment. In this context alone, opioid therapy can be a useful tool in achieving and maintaining an optimal level of pain control in some patients.

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Conflict of interest statement

All TF members declared any potential conflicts of interest (COIs) before the start of the update using the Form for Disclosure of Potential Conflicts of Interest from the International Committee of Medical Journal Editors (http://www.icmje.org/conflicts‐of‐interest/). Potential COIs were independently evaluated by two representatives of EFIC (Sam Kynman, Executive Director and Prof. Hans Georg Kress, Chair of Ethics Committee), who did not participate in the development of this paper. Discrepancies were resolved by consensus. The degree of financial COIs with pharmaceutical companies producing opioids was classified into none, slight, moderate, high, defined as follows:

  1. None: No interaction.

  2. Slight: Only honoraria for lectures.

  3. Moderate: Advisory board; study support.

  4. High: Patent; employee of a pharmaceutical company.

Twelve members of the TF had no COIs, including the three TF chairs (Häuser, Krcevski‐Škvarč, & Vowles). Five members had moderate financial COIs (Drewes, Morlion, O'Brien, Pogatzky‐Zahn, Tölle).

Secretarial support for the drafting of this position paper came from EFIC. The funding of EFIC is detailed in its most recent annual reports which can be found on the EFIC website https://europeanpainfederation.eu/how‐we‐work/annual‐report/. The funding of PAE is detailed in https://pae‐eu.eu/activities/.

Eric Buchser received research funding by Medtronic. Geert Dom received personal fees for advisory board activities by Janssen (Belgium). Asborn Drewes: received research grant by Grünenthal, personal fees for advisory board and/or speaker's activities by Kyowa‐Kirin. Bart Morlion received grants and/or honoraria for clinical research by Novartis, Pfizer, Janssen, Shionogi; for speaker's activitiesby Grünenthal, Lilly, Mundipharma, Pfizer and for consultancy activities by Astellas, Boehringer Ingelheim, Grünenthal, Janssen, Mundipharma, TEVA, GSK, Kyowa‐Kirin, Pfizer, Liilly, Boston Scientific, P&G. Tony O'Brien received an educational grant to Marymount University Hospital & Hospice in support of an international conference to celebrate the 150th anniversary of the foundation by Napp Educational Foundation and received personal fees (lectures) from Mundipharma, Kyowa Kirin and Shionogi Esther Pogatzi‐ Zahn received research grants by Grünenthal and Mundipharma and personal fees for advisory board and/or speaker's activities by MSD, ArcelRx, Janssen‐Cilag and Fresenius Kabi. Thomas Tölle TT received honoraria for consultancies, travel grants and speaking fees for AOP Orphan, Almiral Hermal, Bionest Partners, Benkitt Renkiser, Grünenthal, Hexal, Indivior, Kaia Health, Lilly, Medscape, Mundipharma, MSD, Novartis, Pfizer, Recordati Pharma, Sanofi‐Aventis, and TAD Pharma. The other authors have no financial conflicts of interest to declare.

Figures

FIGURE 1
FIGURE 1
Opioid rotation (modified from Drewes et al. 2013)
See this image and copyright information in PMC

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