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This article has been written for us by:

Susan Barnes, Clinical Nurse Specialist in Pain Management

Royal Bolton Hospital, Lancashire

Sponsored by an unrestricted educational grant from Janssen-Cilag Ltd

The Jury is Out! Opioids for Persistent Non-Cancer Pain

The management of persistent non- cancer pain is a common challenge for both health care professionals and sufferers alike. Opioids are the most effective analgesics available and are considered appropriate treatment for acute and cancer pain. However there have been concerns regarding their usage in persistent non-cancer pain with regard to long term efficacy, tolerance, abuse and fear of addiction. These concerns have been assessed and there is now a consensus view that some patients with persistent non-cancer pain may have less pain and function better if treated with opioids (McQuay,1999; Evans,1999; Schofferman,1993; Portenoy,1986).

Historically national guidelines to inform prescribing practice of opioids in persistent non-cancer pain have not existed, which has hindered the prescribing of these drugs. Recently the Pain Society released their Recommendations for the Appropriate use of Opioids for Persistent Non-Cancer Pain (April 2004). The document was produced in collaboration with the Royal Colleges of Anaesthesia, Psychiatrists, General Practitioners, and the Association for Palliative Medicine and the Royal Pharmaceutical Society.

The recommendations pertain to all opioids available in the UK administered orally or transdermally, only a few of which are licensed for the use of persistent non-cancer pain. The aims of prescribing opioids appropriately are primarily pain relief and to facilitate a rehabilitation plan aimed at improving physical and social function. This in turn may also lead to a reduction in the use of other health care resources.

The recommendations give clear concise guidance on patient selection, assessment, monitoring and the long-term management of opioid therapy. In addition, guidance is given for patients with known psychology co-morbidity or a history of alcohol / problem drug use who may still be considered for opioid therapy with advice or referral to a specialist service with experience of managing these patients.

With the aim of dispelling the myths surrounding the use of opioids and the development of tolerance, addiction and abuse, definitions on these terms have been included. They are supported by evidence to demonstrate that, for example, the use of opioids for pain relief rarely results in addiction and that tolerance is uncommon. Patients and carers may also share these same fears and misconceptions, which need to be explored to help improve concordance.

The key points of the recommendations are highlighted below. For a more detailed account refer to the original recommendations as published by the Pain Society (April 2004).

Patient selection

Patients can be identified as those who are using weak opioids outside the British National Formulary range, and for those who use, or might benefit from strong opioids. A trial of other established therapies such as antidepressants and / or anti-convulsants in neuropathic pain should have been trailed first before commencing an opioid. All patients will require specialised assessments to determine the cause of pain, patient's physical, psychological and social factors and their beliefs, fears and expectations about their pain and opioids. Acute pain teams or other hospital services should not start long-term opioids without the support from a multidisciplinary pain management service and liaison with the patient's primary care team.

Practical aspects of prescribing

Modified release opioids administered orally or transdermally are recommended. Short acting opioids should be reserved for opioid titration and for breakthrough pain. Predictable incident pain to be managed by dose adjustment of sustained release preparations. Pethidine is considered unsuitable for patients with persistent pain or for patients with visceral pain. Opioids should be prescribed and issued at fixed intervals by only one doctor. Individualised treatment plans to be drawn up in conjunction with the patient. Opioid patients require regular assessment, initially at least monthly during dose titration. Evaluation of : pain relief, physical, psychological and social function, sleep, side effects and signs of problem drug use should be documented. Opioid therapy has failed if acceptable pain relief is not attained after dose increments or if intolerable side effects occur. Improved sleep and reduced anxiety do not justify continuing with opioids in the absence of pain relief.

Adverse effects of persistent opioid use

Nausea, vomiting, itching and somnolence are common side effects. With the exception of itching they occur within the first few days of starting opioids and decrease with time. Constipation is common and tends to persist, however, some opioids have a lesser tendency to cause constipation than others. Persistent problems may require opiate cessation or opiate switching. All potential problems should be discussed with the patients. Respiratory depression is rare when opioids are titrated slowly and according to the pain sensation. Other rare side effects include weight gain or loss and hormonal effects.

Patients on a stable dose of opioids are generally fit to drive. However they should not drive during dose titration, if they have taken alcohol or feel cognitively impaired. Patients are responsible for ensuring their own fitness to drive. Patients may need to modify their domestic and work activities whilst getting used to taking opioids. They may need to discuss this with their employers.

Identifying and managing problems

Inadequate pain relief or evidence of developing tolerance should prompt referral to a specialist multi- disciplinary service. Special consideration should be given to patients established on opioids who undergo surgical procedures or are subject to trauma or develop new painful conditions. Such patients need careful analgesic management whilst they have acute pain.

Concerns about problem drug use should prompt referral to specialised services. The following behaviours should cause concern: earlier prescription seeking, claims of lost medication, intoxication, frequent missed appointments and use of other scheduled drugs.

In conclusion the Pain Society's recommendations on the appropriate use of opioids for non-cancer pain will help practitioners to identify patients who may be suitable for an opioid trial. They will also help to inform prescribing practice and dispel the myths surrounding opioids. It may take time to establish local networks and policies between both primary and secondary care services in order to support and implement these recommendations. However the greatest impact will be for sufferers of persistent pain whose ultimate goal is to reclaim control of their lives and to achieve this they must be relieved of pain. Appropriate use of opioids can significantly increase an individual's quality of life and physical functioning; inappropriate use invariably decreases it. With our current knowledge of how pain is generated and alleviated, it is both disrespectful to the patient and a breech of medical ethics not to provide what is clearly needed (Daniel Brookoff, 2004).

Susan Barnes, Clinical Nurse Specialist in Pain Management

Royal Bolton Hospital, Lancashire.