Guidelines for prescribing opioids for chronic non-cancer pain in Korea: can you overcome "opiophobia"?

In the year 2000, the Joint Commission adopted pain as the “fifth vital sign” [1]. Many clinicians have recently paid greater attention to guidelines and policy in pain management [2]. Without strong evidence, clinicians had to rely on their best clinical judgment, influenced by opinion, beliefs, values, and past experience. However, many prescribers proved to be as vulnerable as patients to conflicting messages and judgmental attitudes [2]. Once established, patterns of clinical care can be extraordinarily resistant to change. For this reason, this guideline has been designed to provide criteria for proper prescription procedures for pain clinicians.

Opioids are effective analgesics, but they also have a strong reinforcing potential—fear of addiction and diversion restrict their medicinal use [3]. Good clinical trials, guidelines, and responsible prescription are needed to ensure the availability of opioids for those patients who may benefit [4]. According to the CDC (the Centers for Disease Control and Prevention) guidelines in 2016, many of the preventive recommendations will be familiar to clinicians from principles of good medication management: “Non-pharmacologic therapy and non-opioid pharmacologic therapy are preferred for chronic pain. Clinicians should consider opioid therapy only if expected benefits for both pain and function are anticipated to outweigh risks to the patient. If opioids are used, they should be combined with non-pharmacologic therapy and non-opioid pharmacologic therapy, as appropriate [5].” Pain clinicians should use caution when prescribing opioids at any dosage, should carefully reassess evidence of individual benefits and risks when considering increasing dosage to 50 morphine milligram equivalents (MME) or more per day, and should avoid increasing dosage to 90 MME or more per day or carefully justify a decision to titrate dosage to 90 MME or more per day [5].” These rules are also important to us. But in the United States, abuse or misuse of opioids is a major problem, but in Korea, these concerns are not as important because opioids are used infrequently. Most pain clinicians in Korea have a tendency towards “opiophobia” in opioid prescription. Of course, proper prescription of opioids is very important, but opiophobia should be avoided as well as abuse. Opioids are one of the most important weapons for the pain clinician. Pain clinicians are in a position to control opioid use so that it helps, rather than harms, patients. We recommend that you review this guideline again and apply it to your clinical practice.