Prescription Drug and Alcohol Use Disorders: Safe Prescribing of Opioids.

Opioids are not first-line therapy for chronic noncancer pain or nonsevere acute pain. Overall, evidence does not show that opioids are superior to nonopioid interventions, and opioids pose a high risk of harm. A trial of opioid therapy may be considered for patients who have persistent severe pain plus functional limitations despite adherence to multiple appropriate nonopioid therapies. Individual benefits and harms, including potential adverse effects, overdose risk, and opioid use disorder risk, must be assessed thoroughly before opioid therapy is initiated. A trial period of opioid therapy should be established using immediate-release formulations at low doses. Multimodal management with nonopioid therapies should be continued. Strategies for mitigating risk with long-term opioid use include regular follow-up review of benefits and harms, use of prescription drug monitoring programs, urine drug screenings, and opioid treatment agreements. Caution is indicated when 50 or more morphine milligram equivalents (MME)/day of opioids are prescribed, and dosages of 90 MME/day or more should be avoided. Naloxone should be provided for patients at high risk of overdose. If harms outweigh benefits, opioids should be tapered and discontinued.