Opioid therapy is a cornerstone of severe acute and moderate-to-severe chronic pain management. Yet, resistance to opioid use can be a significant barrier to effective therapy.

Often, concerns about the perceived adverse effects and addictive properties of opioids, and/or regulatory scrutiny, cause these medications to be underused. Documents in this tab section address those concerns and help dispell the many misunderstandings.

Also see the following sections for additional documents of interest:

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= entry added or changed during the latest update.

= Pain Treatment Topics exclusive document.

OPIOID Rx & Safety [General]

This section focuses on dispelling the myths surrounding opioid analgesics. Clinical guidance is provided for more effective application and prescribing of these vital pain medications, with a special emphasis on safety issues to prevent or manage adverse events.

 View all details listings <Click Here> or select item below…

PCCS-O (Prescribers’ Clinical Support System for Opioids)

From: CSAT/SAMHSA and multi-organizational collaboration; 2012-ongoing. See details…>

Online Opioid Conversion Calculator

From: Practical Pain Management journal; 2012. See details…>

Drug-Drug Interactions: Focus on Opioid Use in the Elderly and Long Term Care

By: Lynch T; from American Journal of Managed Care; 2011;17(Suppl 11):S293-S298 See details…>

Pharmacology of Opioids in the Treatment of Chronic Pain Syndromes

By: Ricardo Vallejo, MD, PhD; Robert L. Barkin, PharmD; and Victor C. Wang, PhD; from Pain Physician; 2011. See details…>

Management of Opioid Tolerability and Related Adverse Effects

By: Dmitry Arbuck, MD, et al. from Journal of Medicine, 2010.
See details…>

Managing Chronic Pain with Opioids: A Call for Change

By: Paul Arnstein, PhD, RN; Barbara St. Marie, ANP. Nurse Practitioner Healthcare Foundation. 2010. See details…>


Help for Safely Using Opioids Pain Relievers from Pain Treatment TopicsSee details…>

Patients Who Require Ultra-High Opioid Doses

By: Schneider J, Anderson A, Tennant F. PPM. 2009(Sep);9(7):10+.
See details…>

Opioid Metabolism

By: Howard S. Smith, MD. Mayo Clinic Proceedings. 2009(July).
See details…>

A Comparison of Long- and Short-Acting Opioids for Chronic Noncancer Pain

By: Charles E. Argoff, MD and Daniel I. Silvershein, MD. Mayo Clinic Proceedings. 2009(July). See details…>

Opioid Pharmacology

By: Andrea M. Trescot, MD, et al. Pain Physician. 2008(March);11: S133-S153. See details…>

Opioid Safety in Patients With Renal or Hepatic Dysfunction

From: Pain Treatment Topics – Sarah J. Johnson, PharmD, Updated November 2007. See details…>

Opioid Analgesics for Chronic Pain

By: Mary Lou Bossio, NP; from Advance for Physician Assistants; 2007.

See details…>

Managing Opioid-Induced Constipation

From: Pain Treatment Topics – Clyde R. Goodheart, MD, MBA, MS; Stewart B. Leavitt, MA, PhD, August 2006.
Also: Constipation… from Consumer Reports Best-Buy-Drugs, December 2008. See details of both articles…>

Overview of Oral Modified-Release Opioid Products for the Management of Chronic Pain

By: Calene M. Amabile, PharmD, BCPS, and Bill J. Bowman, BSPharm, PhD. Medscape, Ann Pharmacother; 2006;40(7). See details…>

Opioid Tapering: Safely Discontinuing Opioid Analgesics

From: Pain Treatment Topics – Lee A. Kral, PharmD, BCPS, March 2006. See details…>

Opioids for Chronic Nonterminal Pain

By: Jane C. Ballantyne, MD, FRCA; from Medscape; South Med J, 99(11); 2006. Also: Use of Opioid Analgesics for the Treatment of Chronic Noncancer Pain; from Canadian Pain Society, 2003.

See details…>

VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain

From: Department of Veterans Affairs, Department of Defense; 2003. Also available…

— Opioid Assessment & Treatment Pocket Guide
— Opioid Medications [Dosing] Pocket Guide

See details…>

Opioid/Medication Safety Information for Your Patients

— How to Evaluate Health Information on the Internet
— Proper Disposal of Prescription Drugs
— Facts About Opioids, Methadone, Oxycodone, and Rx Drug Abuse
— Buying Prescription Medicine Online: A Consumer Safety Guide

See details…>

See Opioid Therapy & Safety Guidelines <Click Here>

Also see the following in the Current Comments section…

  • The OIH Paradox: Can Opioids Make Pain Worse? See Details…>
  • Using Objective Signs of Severe Pain to Guide Opioid Prescribing. See Details…>
  • Opioid-Induced Sexual Dysfunction: Causes, Diagnosis, & Treatment.See Details…>
  • Should Opioid Abusers Be Discharged From Opioid-Analgesic Therapy?See Details…>
  • Maximizing Safety with Methadone & Other Opioids.
    See Details…>
  • Overcoming Opiophobia & Doing Opioids Right.See Details…>

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Opioid Risk Management

Besides the potential for opioid analgesia adverse effects, which often can be controlled by safe prescribing practices, the risks of greatest concern have been opioid diversion, misuse, abuse, and addiction. Documents in this section offer guidance for better opioid risk management, including: patient risk assessment, risk minimization, and compliance monitoring.

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SECTION: Managing Opioid Emergencies

What to Know About Opioid Analgesic Overdose

From: Pain-Topics UPDATES, 2012. See details…>

Managing An Opioid Crisis

What to know. What to do.

From: Opioids911-Safety; 2010. See details…>

Emergency Opioid Tapering

Including what to do when medication access is interrupted by disaster.

From: Pain Treatment Topics, 2006. See details…>

Prescribe to Prevent (Naloxone Website)

From: Consortium of experts; 2012 ongoing. See details…>

Opioid Medication Safety: The Role of Naloxone [Video]

From: Prevention Point Pittsburgh; 2012. See details…>

Intranasal Naloxone for At-Home Opioid Rescue

By: Leavitt SB. Prac Pain Managmt. 2010(Oct). See details…>

Naloxone Prescribing Laws in the United States

From: Temple University, Beasley School of Law; Project on Harm Reduction in the Healthcare System. See details…>

Take-Home Naloxone (Website)

From: A consortium in the UK; updated continuously. See details…>

Naloxone – Drug Information (Labeling Info)

From: Merck Manual / Lexi-Comp. August 2008. See details…>

Using Naloxone – Fast Facts (Palliative Care)

By: von Gunten CF, Ferris F, and Weissman DE. Fast Fact and Concept #39: Using Naloxone, 2nd Ed. 2005(Jul). End-of-Life Palliative Education Resource Center. See details…>

Naloxone for the Reversal of Opioid Adverse Effects

By: Marcia L. Buck, PharmD in Pediatr Pharm. 2002;8(8). Reproduced on Medscape, 2002. See details…>

Intranasal Naloxone for Acute Opiate Overdose

From: Tim Wolfe, MD, and colleagues, regularly updated. See details…>


SECTION: Clinical Tools for Assessing Opioid Risks

Clinical Tools for Assessing Opioid Risks

> From PainEDU.org: SOAPP, COMM

> From EmergingSolutionsInPain.com: ORT, DAST, DIRE,
CAGE-AID, SISAP, 5-Point Rx Opiate Abuse Checklist, POSIT

> From Health.Utah.gov: Checklist for Adverse Effects, Function,
and Opioid Dependence

See details for downloading tools….>

Monitoring Opioid Adherence in Chronic Pain Patients:
Tools, Techniques, and Utility

By: Laxmaiah Manchikanti, MD, et al. Pain Physician. 2008(March);11: S155-S180. See details…>


SECTION: Urine Drug Screening/Testing

Urine Drug Testing in Clinical Practice:

The Art and Science of Patient Care

By: Douglas L. Gourlay, MD, FRCPC, FASAM; Howard A. Heit, MD, FACP, FASAM; Yale H. Caplan, PhD, D-ABFT. From: Johns Hopkins University School of Medicine. 2012. See details…>

Interpretation of Urine Drug Testing in Pain Patients

By: Pesce A, et al. Pain Medicine. 2012. See details…>

Clinical Drug Testing in Primary Care – TAP32

From: U.S. SAMHSA/CSAT. 2012(May). See details…>

Urine Drug Testing in Chronic Pain

By: Christo PJ, PJ, Manchikanti L, Ruan X, et al. Pain Physician. 2011. See details…>

A Clinical Guide to Urine Drug Testing:

Augmenting Pain Management and Enhancing Patient Care

By: Catherine A.Hammett-Stabler, PhD, DABCC, FACB and Lynn R.Webster,MD, FACPM, FASAM. From: University of Medicine & Dentistry of New Jersey, Center for Continuing & Outreach Education. 2008. See details…>

Urine Drug Screening: Practical Guide for Clinicians

By: Karen E. Moeller, PharmD, BCPP, et al. Mayo Clinic Proceedings. 2008;83(1):66-76. See details…>


SECTION: General Risk Minimization & Precautions

Use, Abuse, Misuse, and Disposal of Prescription Pain Medication Time Tool

From: American College of Preventive Medicine (ACPM), 2011.

See details…>

Commonsense Opioid-Risk Management in Chronic Noncancer Pain: A Clinician’s Perspective

By: James D. Toombs, MD; from Pain Treatment Topics, August 2007.
See details…>

Avoiding Opioid Abuse While Managing Pain:
A Guide for Practitioners (Book)

By: Lynn R. Webster, MD, FACPM, FASAM, and Beth Dove; June 2007.

See review and ordering info…>

Patient Level Opioid Risk Management

By: Nathaniel P. Katz, MD, MS; from PainEDU.com, Inflexxion, Inc., 2007. See details…>

Assessing Obstructive Sleep Apnea Potential, Which May Affect Opioid Risk (Snore Score)

From: American Sleep Apnea Association. 2007. See details…>

Opioids for Pain: Risk Management

By: Steven Richeimer, MD; from California Society of Anesthesiologists; 2006. See details…>

Rapid-Onset Opioids: Recognizing and Preventing Abuse, Addiction, and Diversion

By: Lara K. Dhingra, PhD, and Steven D. Passik, PhD; from Medscape; 2006. See details…>

Universal Precautions in Pain Medicine:
The Treatment of Chronic Pain With or Without the Disease of Addiction

By: Douglas L. Gourlay, MD and Howard A. Heit, MD, in Medscape Neurology & Neurosurgery, 7(1), 2005. See details…>

Treating Pain and Preventing Abuse and Diversion

By: Brian Goldman, MD, MCFP, FACEP, from LearnSomething.com, 2005. See details…>

Opioid Risk Management – THCI Conference Presentations
From: Tufts Health Care Institute, 2005. See details…>

Also See: “Addiction & Pain Treatment ” Section

Go to section below…>

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Opioid Rx Regulatory & Legal Issues

This section focuses on guidance and mandates coming from government agencies — federal, state, or local — or medical boards regarding the prescribing, dispensing, and administration of opioid medications.

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U.S. FDA ER/LA-Opioid Analgesic REMS

From: U.S. Food and Drug Administration; 2011.
See details…>

U.S. FDA – TIRF-REMS (IR Fentanyl Products)

From: U.S. Food and Drug Administration; 2012. See details…>

DEA – Announcements

From: US Department of Justice, Drug Enforcement Administration. See details…>

DEA Office of Diversion Control – Bulletins

Don’t Be Scammed By A Drug Abuser
A Pharmacist’s Guide to Prescription FraudSee details…>

Practitioner’s Manual — An Informational Outline of the Controlled Substances Act

From: US Department of Justice, Drug Enforcement Administration, Office of Diversion Control, August 2006.

Also availableReference Lists of Controlled Substances.

See details…>

Model Policy for the Use of Controlled Substances

From: Federation of State Medical Boards of the United States, Inc.; May 2004. See details…>

Prescription Monitoring Programs (PMPs)

From: Pain & Policies Study Group, University of Wisconsin and National Association for Model State Drug Laws. See details…>

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The following evidence-based research reports focus on factors involved in safer prescribing of effective methadone analgesia.

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Mathematical Model for Methadone Conversion Examined

By: Fudin J, et al. Practical Pain Management. 2012(September):46-51. See details…>

Methadone-Drug Interactions to Watch For

PCSS Guidance – Methadone and Drug Interactions

From: Physician Clinical Support System for Methadone (PCSS-M); Elinore F. McCance-Katz, MD, PhD; updated July 2010.

 Methadone-Drug* Interactions
(*Medications, illicit drugs, & other substances)

From: Pain Treatment Topics – Stewart B. Leavitt, PhD, 2006.

See details…>

Follow Directions: How to Use Methadone Safely [Public Outreach Campaign]

From: SAMHSA and FDA; 2009. See details…>

Oral Methadone Dosing for Chronic Pain:
A Practitioner’s Guide

By: James D. Toombs, MD; from Pain Treatment Topics, Updated March 2008; reviewed in 2010. See details…>

Methadone Safety Handout for Patients
(in English and Spanish)

By: Stewart B. Leavitt, MA, PhD; from Pain Treatment Topics, Updated March 2008. See details…>

Keeping Patients Safe from Iatrogenic Methadone Overdoses

From: Institute for Safe Medication Practices (ISMP). February 14, 2008.

See details…>

FDA/DEA Public Health Advisories – Methadone Hydrochloride

From: US Food & Drug Administration and the Drug Enforcement Administration; various dates. See details…>

Revised Methadone Prescribing Information (PI) – October 2006

See details…>

Methadone-Associated Mortality – U.S. Government Reports

From: CSAT (Center for Substance Abuse Treatment), SAMHSA (Substance Abuse and Mental Health Services Administration), 2004

  • A National Assessment of Methadone-Associated Mortality:
    Background Briefing Report
  • Methadone-Associated Mortality: Report of a National Assessment

See details…>

Methadone Cardiac Concerns

From: Addiction Treatment Forum – Stewart B. Leavitt, MA, PhD; Mori J. Krantz, MD, FACC. October 2003. See details…>

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Oxycodone, alone and in combination with other analgesics, has been used for more than 80 years in the treatment of a variety of acute and chronic pain conditions. Compared with morphine, oxycodone has higher oral bioavailability and is considered twice as potent.

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Commonsense Oxycodone Prescribing & Safety

From: Pain Treatment Topics – Lee A. Kral, PharmD, BCPS, June 2007. See details…>

Patient Instructions Handout: Safely Taking Oxycodone

From: Pain Treatment Topics – Lee A. Kral, PharmD, BCPS and Stewart B. Leavitt, MA, PhD; in English and Spanish, June 2007.

See details…>

Oxycodone: Pharmacological Profile and Clinical Data in Chronic Pain Management

By: F. Coluzzi and C. Mattia, in Minerva Anesthesiologica, 71(7-8), 2005.

See details…>

Oxycodone: Prescribing Information / Package Inserts (PIs)

See details…>

Criteria for Use of Controlled-release Oxycodone

By: Francine Goodman, PharmD, BCPS; William N. Jones, BSc, MSc; and Peter Glassman, MBBS, MSc.Washington, DC: Veterans Health Administration, Department of Veterans Affairs. Revised July 2003.

See details…>

Safety and Efficacy of Controlled-Release Oxycodone: A Systematic Literature Review

By: D. Gary Rischitelli, MD, JD, MPH, and Sean H. Karbowicz, PharmD. Pharmacotherapy. 2002;22(7):898-904. From Medscape Today.

See details…>

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Addiction & Pain Treatment
The interface of addiction and pain treatment – particularly with opioid analgesics – is a common and vexing problem in clinical practice. This is complicated further by misunderstandings of distinctions between substance misuse, abuse, dependence, addiction, and pseudoaddiction.

This section of Pain Treatment Topics focuses on the clarification, identification, prevention, and treatment of addictive disorders within the context of pain and, conversely, on pain management with opioids in persons having a history of addiction.

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EUROPAD Journal on Addiction

Full editions available for free download as PDF documents. See journal listings…>

Pain Treatment Topics affiliate organization.

When is Rx-Opioid “Addiction” During Pain Care Something Else?

By: SB. Leavitt, MA, PhD; Pain-Topics UPDATES; 2012. See details…>

Basics of Addiction: A Training Manual
for Medical Practitioners on Opioid Dependence

From: Europad Journal on Addiction – June 2011. See details…>

SAMHSA Substance Abuse Treatment Facility Locator

From: U.S. Substance Abuse & Mental Health Services Administration (SAMHSA). Regularly updated. See details…>

NIDAMED Resources for Medical and Health Professionals [Drug Screening]

From: NIDA (National Institute on Drug Abuse); 2009. See details…>

Principles of Drug Addiction Treatment: A Research Based Guide (2nd Edition)

From: NIDA (National Institute on Drug Abuse); Revised April 2009.

See details…>

Best Biomarkers to Detect Underreported Alcohol Use

By: David R. Spiegel, MD; Neetu Dhadwal, MD; Frances Gill, MD. From Current Psychiatry; 2008 (September). See details…>

Challenges in Using Opioids to Treat Pain in Persons With Substance Use Disorders

By: Seddon R. Savage, MD, Kenneth L. Kirsh, PhD, and Steven D. Passik, PhD. From Addiction Science & Clinical Practice (a NIDA publication). 2008(June). See details…>

The Management of Breakthrough Pain With Rapid-Onset Opioids: Abuse, Addiction, and Diversion

By: Steven D. Passik, PhD and Kenneth L. Kirsh, PhD. From Medscape Neurology & Neurosurgery. 2008. See details…>

The New Science of Addiction

From: University of Utah, Genetics Science Learning Center. Updated 2008. See details…>

Safe Treatment of Pain in the Patient With a Substance Use Disorder

By: Penelope P. Ziegler, MD, FASAM; Psychiatric Times (CMP Medica), 24(1), 2007. See details…>

Pain Management Without Psychological Dependence: A Guide for Healthcare Providers

From: Substance Abuse and Mental Health Services Administration (SAMHSA). Substance Abuse in Brief Fact Sheet. 2006(Summer);4(1).

See details…>

Pain in Opioid-Addicted Patients Entering Addiction Treatment

By: Stewart B. Leavitt, MA, PhD, revised July 2006. Adapted from Addiction Treatment Forum, 2004 (Winter);13(1). See details…>

Treatment of Acute Pain in Patients Receiving Buprenorphine/Naloxone for Addiction

By: David Fiellin, MD; from the Physician Clinical Support System (PCSS), 2005. See details…>

ASPMN Position Statement: Pain Management in Patients with Addictive Disease

From: American Society for Pain Management Nursing (ASPMN), September 2002. See details…>

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