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Evidence to Improve Care

Opioid Prescribing for Chronic Pain

Care for People 15 Years of Age and Older

Click below to see a list of brief quality statements and scroll down for more information.

Quality standards are sets of concise statements designed to help health care professionals easily and quickly know what care to provide, based on the best evidence.

See below for the quality statements and click for more detail.

Quality Statement 1: Comprehensive Assessment
People with chronic pain receive a comprehensive assessment, including consideration of their functional status and social determinants of health.

Quality Statement 2: Setting Goals for Pain Management and Function
People with chronic pain set goals for pain management and functional improvement in partnership with their health care professionals. These goals are evaluated regularly.

Quality Statement 3: First-Line Treatment With Non-opioid Therapies
People with chronic pain receive an individualized and multidisciplinary approach to their care. They are offered non-opioid pharmacotherapy and nonpharmacological therapies as first-line treatment.

Quality Statement 4: Shared Decision-Making and Information on the Potential Benefits and Harms of Opioids for Chronic Pain
People with chronic pain, and their families and caregivers receive information about the potential benefits and harms of opioid therapy for chronic pain at the time of both prescribing and dispensing so that they can participate in shared decision-making.

Quality Statement 5: Initiating a Trial of Opioids for Chronic Pain
People with chronic pain begin a trial of opioid therapy only after other multimodal therapies have been tried without adequate improvement in pain and function, and they either have no contraindications to opioid therapy or have discussed any relative contraindications with their health care professional.

If opioids are initiated, the trial starts at the lowest effective dose, preferably below 50 mg morphine equivalents per day. Titrating over time to a dose of less than 90 mg morphine equivalents per day may be warranted in selected cases in which people are willing to accept a higher risk of harm for an improved pain relief.

Quality Statement 6: Co-prescribing Opioids and Benzodiazepines
People with chronic pain are not prescribed opioids and benzodiazepines at the same time whenever possible.

Quality Statement 7: Opioid Use Disorder
People prescribed opioids for chronic pain who are subsequently diagnosed with opioid use disorder have access to opioid agonist therapy.

Quality Statement 8: Prescription Monitoring Systems
Health care professionals who prescribe or dispense opioids have access to a real-time prescription monitoring system at the point of care. Prescription history is checked when opioids are prescribed and dispensed and every 3 to 6 months during long-term use, or more frequently if there are concerns regarding duplicate prescriptions, potentially harmful medication interactions, or diversion.

Quality Statement 9: Tapering and Discontinuation
All people with chronic pain on long-term opioid therapy, especially those taking 90 mg morphine equivalents or more per day, are periodically offered a trial of tapering to a lower dose or tapering to discontinuation.

Quality Statement 10: Health Care Professional Education
Health care professionals have the knowledge and skills to appropriately assess and treat chronic pain using a multidisciplinary, multimodal approach; appropriately prescribe, monitor, taper, and discontinue opioids; and recognize and treat opioid use disorder.


Co-prescribing Opioids and Benzodiazepines

People with chronic pain are not prescribed opioids and benzodiazepines at the same time whenever possible.

Clinicians should not initiate a trial of opioids when benzodiazepines, other sedative hypnotics, or any central nervous system depressants are already being prescribed. These drugs can cause central nervous system depression and decreased respiratory drive and, when combined with opioids, may put people at greater risk of overdose and death.

Before prescribing opioids, prescribers should check for concurrently prescribed controlled substances, both by asking the person with chronic pain and by checking a prescription monitoring system. If a person with chronic pain is taking a benzodiazepine and a trial of opioids is still indicated, a taper of the benzodiazepine should be considered first. In the rare circumstance in which a clinician and a person with chronic pain choose to proceed with concurrent treatment with both an opioid and a benzodiazepine, both the opioid and the benzodiazepine should be prescribed at the lowest effective dose, and the potential harms of this treatment combination should be documented and discussed before treatment is initiated. In these situations, people with chronic pain should be closely monitored for adverse effects such as drowsiness or confusion. If such symptoms occur, one or both drugs should be discontinued. Health care professionals may also consider co-prescribing naloxone for people taking both an opioid and a benzodiazepine.

People taking opioids for chronic pain who also require treatment for anxiety should be offered psychotherapy, an antidepressant, and/or a drug other than a benzodiazepine to treat their anxiety.

For Patients

Whenever possible, you should not take opioids and benzodiazepines at the same time. Benzodiazepines include medications like alprazolam, diazepam, and lorazepam. Taking opioids and benzodiazepines together can cause serious breathing problems.

For Clinicians

Avoid concurrently prescribing opioids and benzodiazepines whenever possible. Ask people with chronic pain about any current opioid or benzodiazepine use before initiating a new prescription for chronic pain or anxiety, and check a prescription monitoring system.

For Health Services

Ensure that tools are available to clinicians to monitor the concurrent prescribing of opioids and benzodiazepines.

Process Indicator

Percentage of people with chronic pain dispensed an opioid and a benzodiazepine

  • Denominator: total number of people with chronic pain dispensed an opioid within a 6-month period
  • Numerator: number of people in the denominator who were dispensed a benzodiazepine within the same 6-month period
  • Data sources: linked administrative databases, including the Narcotics Monitoring System


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