PM01 2020: Opioids in chronic non-cancer pain



·         Summary

·         Associated problems

·         Assessment

·         Alternatives

·         Opioid trialling

·         Tolerance

·         Opioid weaning



·         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



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

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

·         Social environment

·         Risk assessment for misuse



·         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


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