Balance, Pain

Opioids in Chronic Non Cancer Pain? What’s the problem? LifeB4Death Film 16

Don provides an interesting example for us of the challenge of treating chronic pain. Almost all of us do not have a problem with using opioids for cancer related pain.

But what do we do with cancer patients who are living without disease but with pain that is the result of radiotherapy, chemotherapy, or surgery?  When do they become “chronic noncancer pain” patients and when do we “lose our confidence” about prescribing opioids?  Is there are magic moment where we say no more opioids for you? Does one lose the ability to receive chronic opioids when one is no longer “terminal?”

And why should people living with a cancer diagnosis be the only ones with easier access to pain relief that includes opioids?  What about the figures that Michael Cousins shares with us? One in five Australians have chronic pain and one in three of these are severely disabled from their pain. That is one in 15 people living in Australia (6.67%) are severely disabled from pain!!!  Why can’t they have opioids?

Well they can and I look to professional guidance for the how’s, when’s and why’s of chronic opioid therapy for chronic non cancer pain. My preferred guideline is that of the American Pain Society and the American Academy of Pain Medicine written by Chou, Fanciulo, Fine, Adler, Ballantye, Davies et al. They reviewed over 8000 abstracts and ended up with 14 systematic reviews and 57 primary studies. They use standard methods for assessing the evidence, from the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group. In this they look at both the quality of the evidence (high, moderate & poor) as well as the strength of the recommendations. In general, a strong recommendation is based on the panel’s assessment that potential benefits of following the recommendation clearly outweigh potential harms & burdens. What did the guideline committee tell us?

Use of COT (Chronic Opioid Therapy) for CNCP (Chronic Non Cancer Pain) has been steadily increasing for 2 decades. Guidelines based on the best available evidence and developed by multidisciplinary panels of experts are critical for promoting the effective and safe use of COT for CNCP. Although evidence is limited, an expert panel convened by APS and AAPM concludes that chronic opioid therapy (COT) can be an effective therapy for carefully selected and monitored patients with Chronic Non Cancer Pain.

However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The guidelines presented in this document are based on the underlying assumption that safe and effective therapy requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion.

Although these guidelines are based on a systematic review of the evidence on COT for CNCP, the panel identified numerous research gaps. In fact, the panel did not rate any of its 25 recommendations as supported by high quality evidence. Only 4 recommendations were viewed as supported by even moderate quality evidence. Nonetheless, the panel came to unanimous consensus on almost all of its recommendations. Optimally balancing benefits and risks of COT for CNCP is dependent on careful patient evaluation and structuring of opioid therapy to accommodate identified risk, appropriate initiation and titration of COT, regular and comprehensive monitoring while on COT, and anticipation and management of opioid-related adverse effects. Other areas of strong consensus include recommendations to use therapies targeting psychosocial factors and to identify a medical home for all chronic pain patients. Critical research gaps are present in methods for providing informed consent, effective components of opioid management plans, balancing risks and benefits of high-dose opioid therapy, utility of opioid rotation, and treatment of breakthrough pain. More research is also needed on how policies that govern prescribing and use of COT affect clinical outcomes.

The challenge for clinicians to ensure they are trained appropriately in the clinical skills required to prescribe opioids. Already in the US, it seems the Government is taking steps to ensure the appropriate education of physicians.

My biggest concern is that many will opt out of this training, and use this an excuse not to address the suffering of billions around the world!! All physicians need to accept that managing pain, both acute and chronic, is an ethical responsibility for all clinicians!!

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide


One thought on “Opioids in Chronic Non Cancer Pain? What’s the problem? LifeB4Death Film 16

  1. Most patients who are prescribed with opioids for pain, even those undergoing long-term therapy, do not become addicted. The few patients who do develop rapid and marked tolerance for and addiction to opioids usually have a history of psychological problems or prior substance abuse.

    (web site link deleted as link to online pharmacies promoting opioids: jfc)

    Posted by Patient Drug (@DrugPatient) | September 8, 2011, 11:38 AM

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