This is the current release of the guideline.

Chronic noncancer pain

Note: For the purposes of this guideline, all chronic pain disorders outside of cancer pain or pain at end of life are collectively labeled "chronic noncancer pain (CNCP)." Common CNCP conditions include back pain, osteoarthritis, fibromyalgia, and headache. Management of cancer pain, pain at end of life, acute pain, postsurgical pain, or labor pain is outside the scope of this guideline.

To provide evidence-based recommendations for the use of chronic opioid therapy (COT) for chronic noncancer pain (CNCP) in both primary care and specialty settings

Adults with chronic noncancer pain (CNCP), including cancer survivors with chronic pain due to their cancer or its treatment

Note: Management of CNCP in children and adolescents is outside the scope of this guideline.

Evaluation/Risk Assessment

1. History and physical examination
2. Assessment of risk of substance abuse, misuse, or addiction
3. Diagnostic testing

Management/Treatment

1. Informed consent
2. Comprehensive health care by a clinician
3. Therapeutic trial of opioids
4. Methadone
5. Reassess patients periodically (urine drug screens or other information to confirm adherence)
6. Refer high-risk patients to a mental health or addiction specialist
7. Opioid rotation
8. Psychotherapeutic cointerventions
9. Counseling on driving and work safety
10. As-needed approach for patients with breakthrough pain
11. Counseling for pregnant women on opioids

This guideline is informed by an evidence review conducted at the Oregon Evidence-based Practice Center and commissioned by the American Pain Society (APS) and American Academy of Pain Medicine (AAPM) (see the "Availability of Companion Documents" field).

Literature searches included the topics of opioids and chronic pain on the Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, MEDLINE®, and EMBASE through October 2008, using broad terms for opioids or narcotics combined with chronic pain. Searches were also conducted for the following specific topics related to use of opioids (detailed search strategies are shown in Appendix 3 of the original guideline document):

1. Opioid abuse, misuse, and diversion
2. Urine drug screening
3. Driving safety
4. Pseudoaddiction
5. Prognosis
6. Drug monitoring

Reviews of reference lists and expert suggestions supplemented the electronic searches. Studies only published as conference abstracts were not included in systematic searches. Reviews, policy statements, and other papers with contextual value were also obtained.

A total of 14 systematic reviews and 57 primary studies (not included in previously published systematic reviews) were included in the evidence report.

Grading of Quality of Evidence

High Quality Evidence

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes (at least two consistent, higher-quality randomized controlled trials [RCTs]*, or multiple, consistent observational studies with no significant methodological flaws showing large effects).

Moderate Quality Evidence

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes (at least one higher-quality trial* with >100 subjects; two or more higher-quality trials* with some inconsistency; at least two consistent, lower-quality trials*; or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects).

Low Quality Evidence

Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

*Or prospective studies on risk prediction or studies of diagnostic accuracy when appropriate.

This guideline is informed by an evidence review conducted at the Oregon Evidence-based Practice Center and commissioned by the American Pain Society (APS) and American Academy of Pain Medicine (AAPM) (see the "Availability of Companion Documents" field).

The panel developed key questions, scope, and inclusion criteria used to guide the evidence review. For grading the quality of a body of evidence that supports a recommendation, the panel considered the type, number, size, and quality of studies; strength of associations or effects; and consistency of results among studies.

The American Pain Society (APS), in partnership with the American Academy of Pain Medicine (AAPM), commissioned a multidisciplinary panel to develop evidence-based guidelines (see Appendix 1 in the original guideline document for a list of panel members). The guideline panel met in person on three occasions between September 2006 and January 2008. At the first meeting, the panel developed the scope and key questions used to guide the systematic evidence review. At the second meeting, the panel reviewed the results of the evidence review and drafted initial potential recommendation statements. In between the second and third meetings, panelists participated in a multi-stage Delphi process, in which the draft recommendations were ranked and revised. At each stage of the Delphi process, the lowest-ranked recommendations were eliminated. At the third meeting, the final set of recommendations and recommendation grades were finalized and approved. Although a two-thirds majority was required for a recommendation to be approved, unanimous agreement was achieved on all but two recommendations.

Grading Recommendations

Strong Recommendation

Based on the panel's assessment that potential benefits of following the recommendation clearly outweigh potential harms and burdens. Given the available evidence, most clinicians and patients would choose to follow a strong recommendation.

Weak Recommendation

Based on more closely balanced benefits to harms or burdens, or weaker evidence. Decisions to follow a weak recommendation could vary depending on specific clinical circumstances or patient preferences and values.

The guideline developers reviewed published cost analyses.

Over twenty external peer reviewers were solicited. After another round of revisions and panel approval, the guideline was submitted to the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) Executive Committees for approval.

The strength of evidence (high, moderate, low) and the strength of the recommendations (strong, weak) are defined at the end of the "Major Recommendations" field.

1. Patient Selection and Risk Stratification
   • Before initiating chronic opioid therapy (COT), clinicians should conduct a history, physical examination and appropriate testing, including an assessment of risk of substance abuse, misuse, or addiction (strong recommendation, low-quality evidence).
   • Clinicians may consider a trial of COT as an option if chronic noncancer pain (CNCP) is moderate or severe, pain is having an adverse impact on function or quality of life, and potential therapeutic benefits outweigh or are likely to outweigh potential harms (strong recommendation, low-quality evidence).
   • A benefit-to-harm evaluation including a history, physical examination, and appropriate diagnostic testing, should be performed and documented before and on an ongoing basis during COT (strong recommendation, low-quality evidence).
2. Informed Consent and Opioid Management Plans
   • When starting COT, informed consent should be obtained. A continuing discussion with the patient regarding COT should include goals, expectations, potential risks, and alternatives to COT (strong recommendation, low-quality evidence).
   • Clinicians may consider using a written COT management plan to document patient and clinician responsibilities and expectations and assist in patient education (weak recommendation, low quality evidence).
3. Initiation and Titration of COT
   • Clinicians and patients should regard initial treatment with opioids as a therapeutic trial to determine whether COT is appropriate (strong recommendation, low-quality evidence).
   • Opioid selection, initial dosing, and titration should be individualized according to the patient's health status, previous exposure to opioids, attainment of therapeutic goals, and predicted or observed harms (strong recommendation, low-quality evidence). There is insufficient evidence to recommend short-acting versus long-acting opioids, or as-needed versus around-the-clock dosing of opioids.
4. Methadone
   • Methadone is characterized by complicated and variable pharmacokinetics and pharmacodynamics and should be initiated and titrated cautiously, by clinicians familiar with its use and risks (strong recommendation, moderate-quality evidence).
5. Monitoring
   • Clinicians should reassess patients on COT periodically and as warranted by changing circumstances. Monitoring should include documentation of pain intensity and level of functioning, assessments of progress toward achieving therapeutic goals, presence of adverse events, and adherence to prescribed therapies (strong recommendation, low-quality evidence).
   • In patients on COT who are at high risk or who have engaged in aberrant drug-related behaviors, clinicians should periodically obtain urine drug screens or other information to confirm adherence to the COT plan of care (strong recommendation, low-quality evidence).
   • In patients on COT not at high risk and not known to have engaged in aberrant drug-related behaviors, clinicians should consider periodically obtaining urine drug screens or other information to confirm adherence to the COT plan of care (weak recommendation, low-quality evidence).
6. High-Risk Patients
   • Clinicians may consider COT for patients with CNCP and history of drug abuse, psychiatric issues, or serious aberrant drug-related behaviors only if they are able to implement more frequent and stringent monitoring parameters. In such situations, clinicians should strongly consider consultation with a mental health or addiction specialist (strong recommendation, low-quality evidence).
   • Clinicians should evaluate patients engaging in aberrant drug-related behaviors for appropriateness of COT or need for restructuring of therapy, referral for assistance in management, or discontinuation of COT (strong recommendation, low-quality evidence).
7. Dose Escalations, High-Dose Opioid Therapy, Opioid Rotation, and Indications for Discontinuation of Therapy
   • When repeated dose escalations occur in patients on COT, clinicians should evaluate potential causes and reassess benefits relative to harms (strong recommendation, low-quality evidence).
   • In patients who require relatively high doses of COT, clinicians should evaluate for unique opioid-related adverse effects, changes in health status, and adherence to the COT treatment plan on an ongoing basis, and consider more frequent follow-up visits (strong recommendation, low-quality evidence).
   • Clinicians should consider opioid rotation when patients on COT experience intolerable adverse effects or inadequate benefit despite dose increases (weak recommendation, low-quality evidence).
   • Clinicians should taper or wean patients off of COT who engage in repeated aberrant drug-related behaviors or drug abuse/diversion, experience no progress toward meeting therapeutic goals, or experience intolerable adverse effects (strong recommendation, low-quality evidence).
8. Opioid-Related Adverse Effects
   • Clinicians should anticipate, identify, and treat common opioid-associated adverse effects (strong recommendation, moderate-quality evidence).
9. Use of Psychotherapeutic Cointerventions
   • As CNCP is often a complex biopsychosocial condition, clinicians who prescribe COT should routinely integrate psychotherapeutic interventions, functional restoration, interdisciplinary therapy, and other adjunctive nonopioid therapies (strong recommendation, moderate-quality evidence).
10. Driving and Work Safety
    • Clinicians should counsel patients on COT about transient or lasting cognitive impairment that may affect driving and work safety. Patients should be counseled not to drive or engage in potentially dangerous activities when impaired or if they describe or demonstrate signs of impairment (strong recommendation, low-quality evidence).
11. Identifying a Medical Home and When to Obtain Consultation
    • Patients on COT should identify a clinician who accepts primary responsibility for their overall medical care. This clinician may or may not prescribe COT, but should coordinate consultation and communication among all clinicians involved in the patient’s care (strong recommendation, low-quality evidence).
    • Clinicians should pursue consultation, including interdisciplinary pain management, when patients with CNCP may benefit from additional skills or resources that they cannot provide (strong recommendation, moderate-quality evidence).
12. Breakthrough Pain
    • In patients on around-the-clock COT with breakthrough pain, clinicians may consider as-needed opioids based upon an initial and ongoing analysis of therapeutic benefit versus risk (weak recommendation, low-quality evidence).
13. Opioids in Pregnancy
    • Clinicians should counsel women of childbearing potential about the risks and benefits of COT during pregnancy and after delivery. Clinicians should encourage minimal or no use of COT during pregnancy, unless potential benefits outweigh risks. If COT is used during pregnancy, clinicians should be prepared to anticipate and manage risks to the patient and newborn (strong recommendation, low-quality evidence).
14. Opioid Policies Recommendation
    • Clinicians should be aware of current federal and state laws, regulatory guidelines, and policy statements that govern the medical use of COT for CNCP (strong recommendation, low-quality evidence).

Definitions:

Grading Evidence

High Quality Evidence

Evidence includes consistent results from well-designed, well-conducted studies in representative populations that directly assess effects on health outcomes (at least two consistent, higher-quality randomized controlled trials [RCTs]*, or multiple, consistent observational studies with no significant methodological flaws showing large effects).

Moderate Quality Evidence

Evidence is sufficient to determine effects on health outcomes, but the strength of the evidence is limited by the number, quality, size, or consistency of included studies; generalizability to routine practice; or indirect nature of the evidence on health outcomes (at least one higher-quality trial* with >100 subjects; two or more higher-quality trials* with some inconsistency; at least two consistent, lower-quality trials*, or multiple, consistent observational studies with no significant methodological flaws showing at least moderate effects).

Low Quality Evidence

Evidence is insufficient to assess effects on health outcomes because of limited number or power of studies, large and unexplained inconsistency between higher quality studies, important flaws in study design or conduct, gaps in the chain of evidence, or lack of information on important health outcomes.

*Or prospective studies on risk prediction or studies of diagnostic accuracy when appropriate.

Grading Recommendations

Strong Recommendation

Based on the panel's assessment that potential benefits of following the recommendation clearly outweigh potential harms and burdens. Given the available evidence, most clinicians and patients would choose to follow a strong recommendation.

Weak Recommendation

Based on more closely balanced benefits to harms or burdens, or weaker evidence. Decisions to follow a weak recommendation could vary depending on specific clinical circumstances or patient preferences and values.

None provided

The type of evidence supporting most recommendations is specifically stated (see "Major Recommendations").

Safe and effective chronic opioid therapy (COT) for patients with chronic noncancer pain (CNCP)

Patients with sleep apnea or other underlying pulmonary conditions may be at higher risk for respiratory depression and opioids should be initiated and titrated carefully.

An implementation strategy was not provided.

Not applicable: The guideline was not adapted from another source.

American Pain Society

American Pain Society and American Academy of Pain Medicine Opioids Guidelines Panel

Director, APS Clinical Guidelines Project: Roger Chou, MD, Internal Medicine, Oregon Health and Sciences University, Oregon Evidence-based Practice Center

Co-Chairs: Gilbert J. Fanciullo, MD, MS, Anesthesiology/Pain Medicine, Dartmouth-Hitchcock Medical Center, Department of Anesthesiology, Pain Management Center; Perry G. Fine, MD, Anesthesiology/Pain Medicine and Palliative Care, University of Utah, Pain Research Center

Chair, APS Clinical Practice Guidelines Committee: Christine Miaskowski, RN, PhD, FAAN, Registered Nurse/Pain Medicine, University of California, San Francisco, Department of Physiological Nursing.

Panel Members: Jeremy A. Adler, MS, PA-C, Physician Assistant, Pacific Pain Medicine Consultants; Jane C. Ballantyne, MD, Anesthesiology/Pain Medicine, Massachusetts General Hospital, Department of Anesthesia and Critical Care; Pamela Davies, MS, ARNP, Nurse Practitioner/Pain Medicine, Seattle Cancer Care Alliance (Formerly Internal medicine, Veterans Affairs Medical Center, Seattle); Marilee I. Donovan, PhD, RN, Registered Nurse/Pain Medicine, Kaiser Permanente Northwest, Pain Management Clinic; David A. Fishbain, MD, FAPA, Psychiatry/Pain Medicine, University of Miami, School of Medicine, Neurological Surgery and Anesthesiology; Kathy M. Foley, MD, Neurology/Pain Medicine and Palliative Care, Memorial Sloan-Kettering Cancer Center, Pain and Palliative Care Service, Department of Neurology; Jeffrey Fudin, BS, PharmD, DAAPM, Clinical Pharmacy, Samuel S. Stratton Department of Veterans Affairs Medical Center, and Albany College of Pharmacy & Health Sciences; Aaron M. Gilson, PhD, Health Policy, University of Wisconsin Paul P. Carbone Comprehensive Cancer Center, Pain and Policy Studies Group; Alexander Kelter, MD, Public Health, California Department of Health Services, Epidemiology and Prevention for Injury Control (EPIC) Branch (retired 2005); Alexander Mauskop, MD, FAAN, Neurology, New York Headache Center, State University of New York, Downstate Medical Center; Patrick G. O'Connor, MD, MPH, Internal Medicine, Yale University School of Medicine and Yale-New Haven Hospital, Section of General Internal Medicine; Steven D. Passik, PhD, MA, Psychology/Addiction, Memorial Sloan-Kettering Cancer Center, Department of Psychiatry and Behavioral Sciences; Gavril W. Pasternak, MD, PhD, Neuropharmacology, Memorial Sloan-Kettering Cancer Center, Laboratory of Molecular Neuropharmacology; Russell K. Portenoy, MD, Neurology/Pain Medicine and Palliative Care, Beth Israel Medical Center, Department of Pain Medicine and Palliative Care; Ben A. Rich, JD, PhD, Law/Ethics, University of California, Davis, School of Medicine, Division of Bioethics; Richard G. Roberts, MD, JD, FAAFP, FCLM, Family Practice, University of Wisconsin, School of Medicine and Public Health; Knox H. Todd, MD, MPH, FACEP, Emergency Medicine, Beth Israel Medical Center - Pain and Emergency Medicine Institute

All panelists were required to disclose conflicts of interest within the preceding 5 years at all face-to-face meetings and before submission of the guideline for publication, and recused themselves from votes if a conflict was present. Conflicts of interest of the authors and panel members are listed below.

Director, APS Clinical Guideline Project

Roger Chou, MD – Oregon Health & Sciences University - Oregon Evidence-based Practice Center. No conflicts to report

Co-Chairs

Gilbert J. Fanciullo, MD, MS Dartmouth-Hitchcock Medical Center – Department of Anesthesiology, Pain Management Center. Fee Income: Medtronic-Research grant, Speaker, Consultant; Janssen-Research support, Teva Pharmaceuticals- Expert Witness, Pfizer – Educational support for Fellows in Dartmouth Fellowship Program

Perry G. Fine, MD University of Utah- Pain Research Center. Fee Income: Combined honoraria income (exceeding $10,000) from serving on advisory boards related to opioid analgesics for Alpharma, Cephalon, Endo Pharmaceuticals, GlaxoSmithKline, Lilly, Merck, NIH, Ortho-McNeil (J & J), Purdue Pharma, and Wyeth; Total income of above sources over last three years estimated at $30,000.

Ownership interests: 17,500 shares of ZARS Pharma, a privately owned company that develops opioid delivery systems.

Chair, APS Guidelines

Christine Miaskowski, PhD, RN, FAAN University of San Francisco – Department of Physiological Nursing, Fee Income: Consultant/Speaker Bureaus for Anesta, Cephalon, Endo, GlaxoSmithKline, Merck, and Pricara

Panel

Jeremy A. Adler, MS, PA-C Pacific Pain Medicine Consultants, Fee Income: Advisory Board: Alpharma, Speaker's Bureau: Alpharma, Elan, Endo, Pfizer, and Victory pharmaceutical companies.

Jane C. Ballantyne, MD Massachusetts General Hospital-Department of Anesthesia and Critical Care. Fee Income: Harvard International Outreach in Geneva & Bern, Switzerland – 4 weeks sponsored by Novartis, August 2005; Evidence Base of Acute Pain Management Panel of Experts- results published in Anesthesia & Analgesia, sponsored by Orthopedic Review, November 2005. Hydromorphone Expert Panel/Advisory – sponsored by Endo Pharmaceuticals, May 2006; Harvard Medical School received $1,500,000 from Purdue Pharma used to sponsor research and education programs at Massachusetts General Hospital Pain Unit

Pamela Davies, MS, ARNP Seattle Cancer Care Alliance. Fee Income: Received honorarium payments from Alpharma and Endo Pharmaceuticals for work as Clinical Advisor; received honorarium from Endo Pharmaceuticals for work at University of Washington, School of Nursing Continuing Education; total of all honoraria in last 3 years: approximately $5,000

Marilee I. Donovan, PhD, RN Kaiser Permanente Northwest-Pain Management Clinic. Employment: Manager of Kaiser-Permanente Northwest Region Pain Management Clinic; Application for ROI to develop predictors of addiction; Department accepts test equipment from vendors who then sell department equipment and supplies for interventional pain management procedures; Consultant to JCAHO re: pain standards; Clinical lead for outcomes process for Kaiser-Permanente Chronic Pain Guideline

David A. Fishbain, MD, FAPA University of Miami – School of Medicine, Neurological Surgery and Anesthesiology. No conflicts to report

Kathy M. Foley, MD Memorial Sloan-Kettering Cancer Center –Pain & Palliative Care Service, Department of Neurology. No conflicts to report

Jeffrey Fudin, BS, PharmD, DAAPM Samuel S. Stratton Department of Veterans Affairs Medical Center, and Albany College of Pharmacy & Health Sciences. Fee Income: Speakers Bureaus for Advisory Boards: Abbott (less than $10,000), Alpharma (less than $10,000), Calloway Labs, Janssen, and Pricara (division of Ortho-McNeil), Janssen-Research support, Teva Pharmaceutical-Expert Witness

Aaron M. Gilson, PhD University of Wisconsin Paul P. Carbone Comprehensive Cancer Center – Pain & Policy Studies Group. Fee Income-Consulting responsibilities for the American Cancer Society; Honorarium payment for presentations at the Pharmacy Society of Wisconsin and the Federation of State Medical Boards of the U.S., and from Janssen Pharmaceuticals; The Pain & Policy Studies Group at The University of Wisconsin receives unrestricted educational grants from Alpharma, Endo Pharmaceuticals, and Purdue Pharma; Research Funding-Robert Wood Johnson Foundation, Federation of State Medical Boards of the U.S.; Research projects at the Pain & Policy Studies Group at The University of Wisconsin are funded by grants from the American Cancer Society, Susan B. Komen for the Cure, U.S. Cancer Pain Relief Committee, and through a cooperative agreement with the Lance Armstrong Foundation; Project funding is pending for RO3 project at the Pain & Policy Studies Group

Alexander Kelter, MD California Department of Health Services – Epidemiology & Prevention for Injury Control (EPIC) Branch (retired 2005). No conflicts to report

Alexander Mauskop, MD, FAAN New York Headache Center, State University of New York, Downstate Medical Center. No conflicts to report

Patrick G. O'Connor, MD, MPH Yale University School of Medicine and Yale-New Haven Hospital – Section of General Internal Medicine. No conflicts to report

Steven D. Passik, PhD, MA Memorial Sloan-Kettering Cancer Center – Department of Psychiatry and Behavioral Sciences. Fee Income-Consultant/Speaker's Bureaus for Alpharma, Cephalon, Endo, King, Ligand, Lilly, and, Pricara pharmaceutical companies; Honoraria for speaking on pain/addiction and risk management from Ligand, Cephalon, Endo, Alpharma, Purdue, and Mallinckrodt pharmaceutical companies. Research funding-have received grant/research support from Cephalon, Lilly, Amgen, Janssen, and Ligand companies

Gavril W. Pasternak, MD, PhD Memorial Sloan-Kettering Cancer Center – Laboratory of Molecular of Molecular Neuropharmacology. Fee Income-Consultant/Scientific Advisory Boards for Sarentis, Traxon, EpiCept, Limmerick, and QrPahrma companies; Honoraria from Adolor, Endo, Cephalon, and Ortho-McNeil pharmaceutical companies. Research Funding-Have received grant/research support from Sarentis for preclinical evaluation of drug candidates.

Russell K. Portenoy, MD Beth Israel Medical Center- Department of Pain Medicine & Palliative Care. Fee Income-Consulting agreements with an extensive list of pharmaceutical companies, estimated to work with 4-5 within three year period (complete list available upon request). Research funding-Department at Beth Israel Medical Center has received research funding in amounts ranging from less than $10,000 to over $100,000 from several pharmaceutical companies, foundations, and other sources (complete list available upon request)

Ben A. Rich, JD, PhD University of California, Davis – School of Medicine, Division of Bioethics. Fee Income-Speaker honoraria payments from Purdue Pharma, PharmaCon, Pharmacia/Pfizer; Expert consultant/review payment from Purdue Pharma

Richard G. Roberts, MD, JD, FAAFP, FCLM University of Wisconsin – School of Medicine and Public Health. Fee Income-Advisor Board membership payments (less than $10,000 each) from Endo, Ortho-McNeil, and Pfizer

Knox H. Todd, MD, MPH, FACEP Beth Israel Medical Center – Pain and Emergency Medicine Institute. Fee Income-Consulting payments from Johnson & Johnson, Alpharma, ALZA, and Ortho-McNeil pharmaceutical companies. Research Funding-Board of Director member for the American Chronic Pain Association, which has received research funding from Cephalon.

This is the current release of the guideline.

Electronic copies: Available for members only from the American Pain Society Web site .

Print copies: Dr Roger Chou, 3181 SW Sam Jackson Park Road, Mail Code BICC, Portland, OR 97239. E-mail: chour@ohsu.edu

The following is available:

• Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. Final evidence report. American Pain Society; American Academy of Pain Medicine. 2009 Feb. 218 p. Available in Portable Document Format (PDF) from the American Pain Society (APS) Web site .

In addition, the following resources are available in the appendices of the original guideline document :

• Screening and Opioid Assessment Form
• Opioid Risk Assessment Tool
• Sample Informed Consent Form
• Sample Medical Agreement Form
• Monitoring Tool for Pain Assessment and Documentation
• Monitoring Tool for Opioid Misuse

None available

This guideline was completed by ECRI Institute on August 12, 2010.

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Written requests to reproduce any portion of this guideline may be directed to Carlyle Carter at the American Pain Society (APS), 4700 W. Lake Avenue, Glenview, IL, 60025-1485.