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Prescribing drugs of dependence in general practice

Part C2 - The role of opioids in pain management

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Last revised: 02 Jun 2020

 Foreword
 

Pain management is a core general practitioner (GP) skill. But the complex (and sometimes controversial) nature of pain, particularly the management of chronic pain, can push the limits of this skill.

Pain is described as an unpleasant sensory and emotional experience – not a disease.1 In accepting this, we need to understand the nature of patient experience, and realise that there will be no one simple pain treatment for all patients.

Good pain management has significant benefits. For many people, it can transform their quality of life, allowing them to work, be active, and participate in the community rather than being functionally disabled by pain. GPs should take care not to stigmatise patients due to their painful condition or their therapeutic regimes.

In a typical week, 20–40% of adult consultations in Australian general practice involve a chronic pain complaint.2,3 GPs need to feel comfortable managing these patients.2,4 Nowhere is it more important for GPs to have a biopsychosocial approach, in order to provide continuous longitudinal care in a supportive environment. Drug therapies will only ever have a partial role in managing complex biopsychosocial issues that characterise pain management. In the modern health environment, we must explore and use non-drug therapies, and redefine the place for existing medications. It is also important to be able to communicate with patients about the risks and benefits of different pain therapies.

Key to effective pain management is understanding the significant difference between acute and chronic pain with regard to definition, aetiology and complexity. The clinical dilemma remains in that no analgesic drug works well in all patients with chronic pain. Most analgesics work well only in a small proportion of patients. The analgesic adjuvants are also variable in their effectiveness in pain management, and may also have problematic use issues. Despite the risks, opioids remain a necessary therapeutic option in managing some chronic pain presentations.

This guide, in conjunction with Part C1: Opioids, represents a synthesis of the best available evidence for opioids and adjuvants in the primary care setting. In particular, it provides recommendations for GPs who are prescribing opioids for acute and chronic pain outside of active cancer treatment, palliative care, and end-of-life care. This guide addresses when to initiate, continue and discontinue opioids for chronic pain; which opioids to select (with information about dosage, duration, follow-up and discontinuation); and how to assess risk and address harms of opioid use.

In completing this guide, we acknowledge the work of the key advisers and reviewers, and the many people who have provided constructive feedback.

The Royal Australian College of General Practitioners (RACGP) welcomes feedback on this guide to continually improve services at the general practice level. Please use the feedback section on our website to help co-create this guide.

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