Opioids to treat chronic non-cancer pain (CNCP)

Given the lack of evidence that long-term opioids commonly reduce pain or improve the patient’s functioning or quality of life, the harms will often outweigh the benefits.

Common side effects of opioids include nausea, constipation, pruritus, sedation, dental caries, sexual dysfunction and low mood.⁵

Less common but serious side effects include falls, impaired ability to drive, overdose, respiratory depression, cardiac arrhythmias, exacerbation of sleep apnoea and death.⁵

Opioid use may also lead to dependence, withdrawal effects, opioid-induced hyperalgesia, tolerance and a range of personal and societal harms resulting from diversion of opioids.⁵

The balance of benefits and harms may change if the patient becomes more frail, the dose of opioids is increased, or if the patient takes sedative medication or consumes alcohol.

About CNCP

• CNCP is a collection of clinical conditions that involve one 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.¹

Managing CNCP

• CNCP is rarely improved by opioids.
• There is no evidence to suggest long-term opioid use is effective in reducing chronic low back pain,
• osteoarthritis or fibromyalgia.^4,6–8
• There is evidence to suggest that patients who have weaned from high-dose and chronic low-dose opioids had sustained long-term improvements in pain, mood and function.⁹
• The basis for effective pain management is a strong, continuous therapeutic relationship between the doctor and patient,¹ elements of which include:
  • best practice care that is respectful and promotes the patient’s dignity, privacy and safety, even if their use of opioids, alcohol or other drugs is problematic¹
  • providing information and reassurance to enable collaboration, shared decision making and the setting of treatment goals and outcomes that are clear, realistic and agreed upon
  • open discussions about the more difficult aspects of pain management, such as the prescription monitoring service, responsible prescribing, opioid contracts, tapering doses, transitioning to opioid replacement programs and the use of a chronic pain team or tertiary referral.¹

Minimising harm in patients using opioids for CNCP

• When patients are already using prescribed opioids, minimise the risk of harms by conducting close clinical monitoring, using real-time prescription monitoring programs, reviewing co-prescriptions of other sedating medications and initiating staged deprescribing with consent.
• If a patient is at risk of overdose, facilitate access to naloxone.

The following list contains examples of complex situations where a pain specialist or multidisciplinary review should be considered.

• A patient taking two or more psychoactive medications (eg antipsychotics or antiepileptics and opioids)
• A patient taking opioids and benzodiazepines in combination
• A patient with complex mental health comorbidities or living with enduring mental health symptoms
• A patient with a history of, or living with, substance abuse problems
• A new patient requesting opioid medications where there is no established therapeutic relationship or where a therapeutic relationship is not possible
• A patient recently discharged from a correctional facility or with a significant forensic history
• A patient displaying signs of potential high-risk behaviour
• A patient with a history of suicidality or drug overdose
• Unexpected dose escalation
• High levels of patient distress

Appropriate multidisciplinary reviews may include community pharmacists, drug and alcohol services and mental health or psychiatry professionals.⁴

Consider non-pharmacological therapies

Extensive evidence suggests there are some benefits of and less harm from using non-pharmacological and non-opioid pharmacological therapy.⁶ Non-pharmacological therapy may include:^10,11

• psychological interventions such as cognitive behavioural therapy, behavioural therapy and acceptance and commitment therapy
• physical therapies that aim to improve goals of function, despite baseline persisting pain, such as general strengthening, yoga, hydrotherapy and Tai Chi
• involvement of a multidisciplinary team (eg occupational therapist, physiotherapist and/or psychologist).

Educate the patient about pain and pain management

There is evidence to suggest that a program that educates patients about the nature of pain, its effects and how it is perceived by the brain can help manage expectations and promote self-management to achieve short-term reductions in pain and disability and decrease catastrophising (see Resources and information for patients).^1,12 Typically, this would include dedicated consultations over an extended time, rather than, for example, just giving the patient an information sheet.

Encourage regular activities

• Encourage your patient to return to normal activities because there is strong evidence that patients with CNCP who are physically active experience a reduction in pain levels and an improvement in function and wellbeing.
• Encourage your patient to return to work (where appropriate) because this may reduce morbidity and improve wellbeing.¹

• NPS MedicineWise, Opioid medicines and chronic non-cancer pain
• NSW Government Agency for Clinical Innovation, self-management of pain resources
• Pain Australia, The nature and science of pain
• Pain Australia support groups and help lines
• The Royal Australian College of General Practitioners, Opioids to treat long-lasting pain
• University of South Australia, Professor Lorimer Moseley discusses his experience with pain for Feeling Human at MOD

• RACGP, Prescribing drugs of dependence in general practice, Part C1 – Opioids
• RACGP, Prescribing drugs of dependence in general practice, Part C2 – The role of opioids in pain management
• RACGP, Handbook of non-drug interventions (HANDI)
• RACGP, AOD clinical advisory service and S8 prescribing in your state or territory
• The University of Sydney, Evidence-based clinical practice guideline for deprescribing opioid analgesics