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

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Winfried Häuser, Bart Morlion, Kevin E. Vowles, Kirsty Bannister, Eric Buchser, Roberto Casale, Chenot Jean-François, Gillian Chumbley, Asbjørn Mohr Drewes, Gert Dom, Liisa Jutila, Tony O'Brien, Esther Pogatzky-Zahn, Martin Ragusa, Carmen Suarez–Serrano, Thomas Tölle, Nevenka Krcevski–Škvarc

Original languageEnglish
Pages (from-to)949-968
Number of pages20
JournalEuropean Journal of Pain (United Kingdom)
Issue number5
Accepted/In press2021
PublishedMay 2021

Bibliographical note

Funding Information: Eric Buchser received research funding by Medtronic. Gert Doom 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. Publisher Copyright: © 2021 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC ®. Copyright: Copyright 2021 Elsevier B.V., All rights reserved.

King's Authors


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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