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.