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Prescribing drugs of dependence in general practice

Part C2 - The role of opioids in pain management

A summary of opioid use in chronic non-cancer pain in general practice

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Last revised: 02 Jun 2020

Chronic pain has historically been defined as continuous or recurrent pain that persists for an extended period (generally more than three months). However, the biological mechanisms for chronic pain are quite different from those of acute nociception, and should not be considered as ‘unhealed’ acute pain. Chronic non-cancer pain (CNCP) is a collection of clinical conditions with involvement of single or multiple pathophysiological mechanisms leading to persistent pain. It is also an individual, multifactorial experience influenced by culture, previous pain events, beliefs, expectations, mood and resilience.

Due to methodological weaknesses of chronic pain studies, interpretation and translation of evidence into practice is difficult. There is limited evidence to determine long-term benefits of opioids (outside of end-of-life care); however, there is evidence of risk of harm that increases with dose. While guidelines suggest opioids in the management of some chronic pain conditions, they are not recommended for routine or first-line use.

For accountable prescribing in managing CNCP, GPs should:

  • undertake a complete biopsychosocial assessment of the patient with pain
  • optimise non-drug therapies, and optimise non-opioid therapies as the primary interventions of care.

Opioids for CNCP should be reserved for selected patients with moderate or severe pain that has not responded to other therapies and that significantly affects function or quality of life. If primary interventions fail or are suboptimal, opioid therapies may be considered. GPs should share the decision-making process with the patient, and if opioid therapy is considered, there should be:

  • a patient selection/exclusion process before a therapeutic opioid trial
  • formal care planning based on specific goals and risks
  • an opioid trial, which is undertaken to determine a patient’s response to opioid therapy. This trial includes the selection of an appropriate opioid, formal measures of analgesia and functionality, a trial of dose reduction, and a drug cessation plan if the trial fails
  • an ongoing assessment and evaluation by the accountable prescriber if the trial shows opioid benefit
  • opioid tapering and cessation if suboptimal results or aberrant behaviour occurs.

Long-term use should be uncommon, undertaken with caution and based on consideration of the likely risks and benefits of opioids. Intermittent use is preferable.

GPs should also be aware of chronic pain conditions where there are known clinical complexities involving opioids. These complex clinical areas include the exacerbation of pain or new acute pain in patients on long-term opioid therapy, managing opioids after a non-fatal overdose, and managing the inherited patient.

Some patients on long-term treatment with opioids for CNCP may represent de facto maintenance treatment for iatrogenic opioid dependence. GPs should aim to taper patients taking >100 mg oral morphine equivalent (OME) per day.

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