The use, overuse and misuse of opioids in pain management is very topical.
For many years opioids have been regarded as the “gold standard” in pain management. Initially they were reserved for cancer pain but very quickly they found a role in treating acute and chronic pain. The use of the long-acting products in particular have come under the microscope in the USA and in Europe because of the associated side effects including death from drug overdose. In the USA the estimated with an annual economic toll of chronic pain is between $560 billion to $635 billion.
In the ideal world we would avoid opioids in chronic pain but in practise this is not realistic...
In this month’s edition of “GP Ireland” ( the official publication of the National Association of General Practitioners) Dr. Dominic Hegarty (Clinical Director of Pain Relief Ireland) says that “ In the ideal world we would avoid opioids in chronic pain but in practise this is not realistic, therefore, I would propose, that there are 3 key areas to focus on from an Irish perspective that would help guide good decision making”. These include:
- How determine when to initiate or continue opioid therapy for chronic pain;
- Planning the selection, dosage, duration, follow-up.
- How to Assess Function and Halting Opioids.
It is Dr. Hegarty’s opinion that having an “exit” strategy for concluding opioid therapy is just as important as having a good reason to start an opioid. Setting out and writing down clear outcome “goals” is an important step in the treatment planning. These could include:
30% Improvement in functional ability
While pain relief is essential, the CDC guidelines also that functional goals are likewise important. These functional goals, in fact, may actually be more relevant than numeric pain scales to typical chronic noncancer pain patients. For instance, patients may set goals of being able to walk to the shop or sit comfortably to watch television. In the initial days and weeks of opioid therapy, prescribers and patients should discuss whether opioids are helping the patients meet their goals.
Side effects profile
Patients should be alerted to both transient and more persistent side effects. After trying an opioid analgesic for a short period of time, physicians should monitor their patients for side effects and tolerability, and assess whether the opioids have reduced their pain.
When a given opioid analgesic is ineffective or intolerable, clinicians should determine whether another opioid might be more effective or better tolerated. Opioid rotation maybe an important clinical strategy. Guidance with a pain specialist might be useful. In other cases, patients may decide to continue with nonopioid analgesics, nonpharmacological pain options, or other techniques such as interventional pain therapies and device based therapies. Particularly challenging cases may be referred to a pain specialist.
Opioids are valuable and useful tools to help individuals deal with pain. The recent media reports, with alarming reports of widespread abuse and misuse have caused many clinicians to limit their prescribing of opioids or to make opioids “off limits” as a pain control option. In reality, opioid therapy is often appropriate for a subset of pain patients. However, GP’s should be clinically prudent and weigh up all pain control options when they try to offer the best pain management regime for their patient.
Abstract from the full article “Effective Opioid Management of Chronic Pain in Primary Care” written by Dr. Dominic Hegarty in GP Ireland, Dec/Jan 2019 Volume 4 Issue 10 pg 36-38.