Opioids for Persistent Pain

Below are some of the main points to consider when reviewing patients taking opioids for persistent pain or when considering initiating this type of medication.

1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.

2. A small proportion of people (approximately 20%) may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation).

3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit (an online opioid convertor calculator can be found at www.paindata.org).

4. If a patient is using opioids but is not experiencing sufficient pain relief and functional improvement, the opioids are not effective and should be discontinued, even if no other treatment is available.

5. Chronic pain is complex and multi-factorial, focus should be on functional improvement and pain management strategies, not only pain reduction. Please consider referring patients to the community pain services before initiating strong opioid therapy (Adapted from the Faculty of Pain 2016).

Practical Opioid Prescribing:

1. Emphasise the important role of physical, social and self-care strategies (exercise, socialising, hobbies, pacing and relaxation).

2. Pursue non-pharmaceutical treatment strategies (Physiotherapy, Community Pain Management)3. Ensure appropriate non-opioid medications have been prescribed prior to commencing opioids –

simple analgesics, adjuvants, topical treatments. Ensuring the doses are at therapeutic levels. 4. Differentiate with patients the goals of short term vs long term pain relief5. Provide patients with information on the short-term and long-term adverse effects of opioids

Short term side effects Long term side effects Sedation Nausea Constipation Dizziness Itching Dry mouth Interaction with other CNS

depressants such as alcohol.

Tolerance and hyperalgesia Cognitive impairment Depression Constipation Sexual dysfunction Falls and accidents Dependence and addiction

6. Systematically evaluate patients for risk of developing opioid misuse disorder using an opioid risk assessment tool.

The most important risk factors are: previous history of substance misuse, mood disorders – anxiety and depression family history of substance misuse poor social supports

7. Establish an agreed trial period with agreed goals – preferably with physical and social function goals, eg A one month trial – goal of increasing working hours and socialising. If the goals are not achieved the opioid trial should be discontinued.

8. Avoid long-term use without clear benefit. If goals are not met then seek alternative strategies. Specialist opinions may be appropriate, such as referral to community pain service.

Information adapted from Opioid Aware website, further information can be found at:

https://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware