Prescribing Opioids - Information for Health Professionals
The Faculty of Pain Medicine of the Royal College of Anaesthetists has produced a very useful information site on opioid prescribing, Opioids Aware, that is highly recommended. It contains excellent and very useful information both for patients and prescribers.
Opioids could potentially be used, either short-term or long-term, for any severe pain. Some of the key principles that apply to these drugs include the following:
Selecting the Therapy: Opioids are typically first-line if the pain is severe and is expected to be short-lived, like post-surgical pain, and if the pain is associated with a progressive incurable illness. In other types of chronic pain, a decision to try an opioid should be based on a careful evaluation by the clinician. This evaluation should try to answer several questions: Is the pain severe enough to warrant this therapy? Are there other therapies just as safe as the opioids that might work as well or better? Is the use of an opioid complicated by some medical problem that makes them relatively less safe? Is this patient likely to be responsible with these drugs, or is there some indication that drug-taking behaviors might become a problem?
Individualize the Therapy: For short-term therapy, a short-acting drug is usually selected. For longer term therapy, a long-acting drug is preferred. Whatever drug is selected, the key to successful therapy is gradual adjustment of the dose until a favorable balance between pain relief and side effects is attained. If this favorable balance is not possible with one drug, a switch to another opioid might be considered.
Treat Side Effects: Many patients will need treatment for constipation during therapy. Some will need a medicine for nausea. During long-term therapy, some physicians will administer a stimulant drug if the pain control is good but therapy is compromised by sleepiness, fatigue or mental clouding.
Consider Other Therapies: Patients with chronic pain often do best when one or more pain-relieving drugs are combined with other therapies, including rehabilitative approaches, psychological therapies, injections, or CAM approaches.
Follow the Appropriate Outcomes: There are four types of outcomes that should be monitored by the physician prescribing an opioid therapy: 1) pain relief, 2) side effects, 3) physical and psychosocial functioning, and 4) the occurrence of any aberrant drug-related behaviors. Patients should be made aware by their prescribers that there are a wide variety of side effects possible with the use of these medications. It is important that patients talk with their providers about any changes they have noticed in any area of their lives since beginning a new treatment regimen. Patients can help by being prepared to discuss these outcomes with the prescriber.
Opioids and driving
The MHRA have just (2014) released an information leaflet on driving while on certain medications, including opioids, which is linked here. Further information on this is linked here.
We highly recommend the Opioids Aware site discussed above.
The use of opioids for chronic non-cancer pain is not without resulting issues and problems. In this video presentation from the Pain Community Centre in Cardiff, our colleague Dr Cathy Stannard discusses these.
Further details are given in the Gloucestershire Joint Formulary website, and on this is a useful opioid equivalence chart. This chart may also be helpful. A useful resource for considering the various costs of opioid preparations can be found here.
The Scottish Intercollegiate Guidelines Network (SIGN) has published, in November 2013, guidelines on Chronic Pain including a comprehensive advisory pathway on prescribing of opioids, which should hopefully also be helpful.
Opioids for persistent pain: Good practice (2010)
A consensus statement prepared on behalf of the British Pain Society, the Faculty of Pain Medicine of the Royal College of Anaesthetists, the Royal College of General Practitioners and the Faculty of Addictions, Royal College of Psychiatrists.
This document can be downloaded free of charge by clicking this link or the image below. This publication includes the information pamphlet Opioids for persistent pain - information for patients (available on the British Pain Society's patient pages ).
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Pain Service Website, Gloucestershire Hospitals NHS Foundation Trust
Webmaster Dr J G de Courcy, Consultant in Pain Medicine and Anaesthesia
Page updated 7/12/2016