Discussion
Avoid Opioids If Possible
There is little good quality evidence to support the effectiveness of opioids for chronic pain, most of the published trials lasted no more than 4 months, they excluded high-risk individuals and they did not assess addiction risk 4. There is no consensus on how opioids compare with alternative pharmacological options such as tricyclic antidepressants, muscle relaxants and NSAIDs in treating musculoskeletal pain, but there is an increasing body of literature surrounding the development of tolerance and pain sensitization caused by endogenous and exogenous opioids, resulting in a decrease of its analgesic effects 4,5. Patients may still take opioids despite waning of analgesic effects due to dependence or addiction whereby using opioids helps to relieve withdrawal symptoms6.
Alternatives to Opioids
The Centres for Disease Control and Prevention (CDC) recommend the use of non-pharmacological (CBT and exercise therapy) and non-opioid options as first-line treatment for chronic pain 7. Increasing physical activity is a low-cost intervention with minimal risks which can improve pain levels, improve physical function and reduce work disability. Biopsychosocial interventions such as pain management programmes (PMPs) are aimed at addressing the complexities faced by patients with chronic pain. PMPs are delivered in group settings by an interdisciplinary team working closely with patients8. Patients that have undergone a PMP have demonstrated improvements in pain intensity, pain-related beliefs such as catastrophising, mood, and pain-related disabilities8. Live Well with Pain is a free online resource that aims to help patients to self-manage. The online site includes a section called the Opioid Thermometer which is targeted to think about the doses of medication they are taking and serve as a reminder of the harms associated with opioids 9. There is also a Pain Toolkit that guides patients on how to self-manage their pain9.
Practical Steps in Opioid Prescribing
The CDC 7 and Opioid Aware 10provide guidelines and practical steps in opioid prescribing, describing how to undertake an opioid trial, and how to taper and stop opiates. Both resources highlight the need to establish goals for pain management and emphasise that complete pain relief should not be the goal, but rather reducing pain enough to engage in self-management. Both also recommend keeping a record of adverse effects, dosing, discussions about risks and benefits, and circumstances under which prescribing should cease. Opioid therapy should be discontinued if the benefits are outweighed by the adverse effects. Opioid Aware recommends involvement of relevant medical specialties such as mental health and substance abuse if the patient presents with complex needs. Good communication and shared decision-making are essential parts of good care 3.
An Opioid Trial
Opioid therapy should only be considered if other multimodal therapies have not yielded adequate improvements in pain and function. Patients should only start an opioid trial if they do not have contraindications for opioid therapy and after a discussion about the potential harms and benefits of opioid therapy 3. An opioid trial helps to establish if the patient has a reduction in pain with the use of opioids. Managing side effects and achieving optimal doses can be further explored if opioid therapy is pursued after a trial10.
Opioid Aware provides some practical steps on how to conduct an opiate trial. A trial should first begin with a discussion with the patient on assessable outcomes such as achieving functional improvements e.g. attending work, exercise and sleep. A trial can last for 1-2 weeks and patients should start on low dose of immediate-release morphine (liquid or tablets). The patient could be advised to explore a range of doses between 5-10mg of morphine. To assess success, a diary should be kept during the trial, with a twice-daily record of outcomes discussed such as pain intensity, activity level and sleep 10.
Tapering and Stopping Strong Opiates
Tapering means reducing doses whilst minimising withdrawal symptoms, often with the aim of complete discontinuation 3. Abrupt discontinuation can result in opioid withdrawal symptoms5. Consider tapering in the following circumstances: patient preference, no significant improvement in pain and function, on doses ≥50 morphine milligram equivalents (MME) per day without benefit, suspected substance use disorder, overdose, serious adverse events or concerns about dependence 5. Consider dependence in the following scenarios: long-term use for non-malignant pain, history of psychiatric illnesses or emotional trauma, history of substance misuse, problems with prescriptions (lost prescriptions, early requests, taking higher doses than prescribed), family members are concerned about opioid use, refusal or failure to attend medication reviews, ‘doctor shopping’ for prescriptions, functional deterioration (e.g. being unable to work) and declining specialist referral to assess the underlying problem 3. Before tapering, discuss the rationale and potential benefits with the patient, agree on outcomes and an appropriate time frame and discuss signs and symptoms of withdrawal. The dose should be tapered by 10% weekly or two-weekly 3.