PM01 2020: Opioids in chronic non-cancer pain

List:

· Summary

· Associated problems

· Assessment

· Alternatives

· Opioid trialling

· Tolerance

· Opioid weaning

Summary:

· No good in chronic non-cancer pain, even if pain score is high

· Plenty of harm: tolerance, dependence, addiction, overdose, sleep apnoea, cognitive impairment, unsafe driving, falls, osteoporosis, sexual dysfunction, constipation

· Especially dangerous in combination with alcohol, benzodiazepines

· Once started, very difficult to stop

· Diverts focus from alternatives (see below)

Associated problems:

· Multiple pain conditions

· Social problems: unemployment, welfare dependence

· Psych problems: childhood abuse/neglect, depression, alcohol

· Risk factors for misuse: youth, absence of medical diagnosis, psychiatric disorder, other drug use, contact with drug user

Assessment:

· Pain history: time course, quality (including neuropathic)

· Psychological state: including beliefs, mood state, behaviours, responses

· Social environment

· Risk assessment for misuse

Alternatives:

· MDT: pain specialist, psychologist/psychiatrist, addiction med, rehabilitation med, physiotherapy, occupational therapy, dietician, social worker

· Basic: housing, nutrition, sleep hygiene, exercise, work, social engagement

· Psych: CBT, mindfulness, neuroscience education

· Analgesics: paracetamol, (NSAIDs if inflammation), TCAs, SNRI, gabapentinoids

If trialling an opioid:

· State the plan and goals

· Monitor 5As: Analgesia, Activity, Adverse effects, Affect, Aberrant behaviour

· Use long-acting drug drug (minimizes positive reinforcement)

· Titrate over several weeks

· Ceiling effect controversial; oMEDD caution >40, not good >100

· Note lowest dose fentanyl patch (12mcg/h) is close to oMEDD 40mg

If opioid stops working:

· Drug problems: tolerance -> ↓effect ↓duration, side effects

· Psychosocial problems: aberrant behaviour, life problems

· Rotate opioid if suspect tolerance

Opioid weaning after long-term use:

· Aim for cessation within 3-9 months

· Aim 10-25% dose per week; slower if not tolerated

· If significant adverse effects or misuse, suggest daily reduction or cold turkey

· Addiction may become apparent; if so, refer to appropriate service

Feedback welcome at ketaminenightmares@gmail.com