Opioid usage for patients with long term chronic pain

23 Nov 2017 By Views : 2123

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Opioid usage for patients with long-term chronic pain

The challenge of treating patients with long-term chronic pain is a particularly difficult one, given that the number of options is limited. The current concerns are that patients with long-term pain resorting to opiates, in cases where they offer very little benefit (if at all) and subjecting users to worrying risks (side effects are present in 50-80% of cases), is increasing. This is reflected in the cost of opioid prescribing.
Where opiates are proven to be useful however, is in the management of end-of-life and acute pain. Taking opiates in short bursts for a flare-up is quite common and appropriate practice. Clinicians rarely prescribe opiates for long term pain and research shows that most patients become dependent on opiates only after taking them for an acute event.
The greatest danger lies in long-term opiates usage, where the patient may be increasing doses and not really experiencing any pain significant pain relief, but instead developing a dependency. Patients in this category are at risk of becoming addicted (if they aren’t already), together with impairment in doses of >120mg morphine or equivalent.  Importantly, at this dose the opiate does not provide any increased pain relief, but does pose an increased risk of side effects.
The facts:
  1. A dose greater than 120mg morphine (or equivalent) provides no added pain relief, but does subject the patient to a higher risk of harm.
  2. A dose greater than 220mg morphine (or equivalent) causes impairment similar to being over the legal limit of alcohol and driving should not be attempted.
  3. Compared to NSAIDs, in patients 80+, opiates have a higher rate of hospital admission and all-cause mortality.
  4. Emotional dependence on opioids is more likely in patients with a history of mental health problems, personality disorder, sexual and physical abuse. They are also likely to increase the dose.
  5. Chronic opioid use is associated with reduced quality of life and employment status, and increased pain, healthcare use and mortality.
What to do?
The stark message is that if a patient is already taking 120mg morphine or equivalent and there is no significant improvement in their pain or functionality, then continuing the drug is resulting in more harm than good.
The best course of action is to taper the dose and wean them off completely, with the idea that this will give them a better quality of life despite the pain. Additionally, avoid concurrent use of benzodiazepines and other CNS drugs likely to contribute to respiratory depression, in order to mitigate the risks of opioid related death.
When initiating treatment for acute pain, establish goals centred on quality of life and functionality, not pain. The plan should also include agreed withdrawal in the event of limited improvement, in order to combat the risks posed.
Patients with acute pain should be given 3 days of opioid treatment, with up to a maximum of 7 days. Those that are suffering from post-surgical pain should have the treatment duration clearly stated on the discharge.
After initiation, longer opioid courses should be reviewed after two weeks with a view to stop, as well as for efficacy and safety and dose adjustments.
If a patient is still experiencing pain despite opioid usage, then they should be stopped even in the absence of alternative treatment.
Be aware of and address underlying anxiety and depression/ mental health issues.
What not to do?
Dose increases should not take place pressure during a consultation; team decisions for complex patients shares the load and helps to manage patient expectations
Two or more opioids should not be prescribed concurrently. In such cases, the weaker one is of no use and should be ceased immediately.

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