Many people who are seen in the pain clinic are on some type of morphine like medication. These drugs- called opioids- include; morphine, oxycodone, pethidine, methadone, fentanyl and codeine.
Opioids are rarely (probably less than 2%) prescribed for our patients. This is because most studies to date have really failed to demonstrate effective long term benefit for the management of persistent non-cancer pain. Importantly they do cause problems with bowel function, concentration, attentiveness, breathing and sleep,and can have important hormonal effects. They are particularly prone to patients becoming dependent on them and in rare cases addiction.
The real risk with opioids is that they can increase rapidly in dose with no great effect on either pain intensity or function. There are worrying international data clearly showing rising prescription for opioids in the face of rising levels of persistent pain and deaths associated with opioids. The risk is not only for patients who have these medications prescribed but also from drugs that are lost, taken at wrong doses, taken with sedatives including alcohol , and stolen and sold on the black market. The USA, UK and Australia are frequently reporting such complications.
Why are patients then prescribed opioids?
- The initial prescriber considers the medication to be a rationale choice.
- No specific criteria are used for dose, duration or specific end points and no regular reviews are organised.
- There are no other medications which work
- The prescriber is unaware of the potential risk
- The prescriber is coerced by the patient to prescribe opioids.
Are are there any cases in which opioids can be prescribed?
- Time, dose and function related after major surgery. In many cases patients are discharged form hospital with a prescription for opioids. There is no indication as to suggested duration and not uncommonly these are continued by their GP for variable time. In this case regular reviews are needed to understand the recovery process.
- To allow time and function contingent activity to begin. In cases of prolonged inactivity there may be a few patients who may benefit from a short (<3 months) course of strong pain medications to to allow initial activation. These should be weaned after pre-determined and agreed end points are met.
- In some cases of severe or escalating pain where all medications have been trialled AND the risk of complications is low.
Can prescribing of opioids be made safer? Probably yes if the decision is taken in partnership with patient and prescriber. If your pain condition is deemed potentially suitable for a trial of opioids we suggest the following plan.
1. Agree on defined and measurable end points- simply 'feeling better' but not doing more or being more functional is not enough as the risks outweigh any advantage.
2. Agree on single prescriber.
3, Agree on opioid agreement- the prescriber agrees to prescribe for a defined time period and then review outcomes. There will be only one prescriber and medications should only be dispensed from one pharmacy. The prescriber will assess effectiveness and possible side effects. The patient understands and agrees to the plan, and understands that failure to achieve agreed goals will result in slow weaning and stopping of opioids. This is standard practice in most pain clinics and the relevant paperwork can be accessed from the Waitemata Pain Services.
Suggested reading. For those interested to find out more about this challenging area, we have included resources from the Faculty of Pain Medicine (ANZCA) our local specialist pain educational body as well as others from overseas and locally. many are targetted at medical practitioners but are of interest to patients and caregivers as well.
Guidelines for opioids in non cancer pain from the Faculty of Pain Medicine (Australia and New Zealand) FPMANZCA-Opioids.pdf
Opioid prescribing in primary care. This is a format of prescribing which may be applied if you are embarking on a trial of opioids or have been on opioids for a long time and your prescriber is considering how effective they may be for you overall management.Opioids-MJA-GP.pdf
Opioids and addiction is a document looking at local practice and comparing with overseas experience. NZ-opioid-addiction.pdf
Information on specific opioids