‘We are super aware of the harms – the constipation, the depression, the tolerance,’ says Dr Jennifer Stevens, anaesthetist and pain specialist at Sydney’s St Vincent’s Hospital Campus.
‘But many clinicians still think there is an upside to opioids and it’s worth taking those risks.’
In managing chronic non-cancer pain, however, this couldn’t be further from the truth, Dr Stevens says.
There is mounting evidence that opioids, particularly slow-release formulations, are ‘less helpful and more problematic than we ever thought’, she says.
‘It just makes patients’ lives so much harder.’
The evidence is in
Dr Chris Hayes, Pain Medicine Physician at John Hunter Hospital, NSW, says while opioids retain a role in the management of acute pain, cancer pain and palliative care, three 2018 studies (here, here and here) have strengthened the evidence that opioids are ineffective for chronic non-cancer pain.
Speaking for the Australian Commission on Safety and Quality in Health Care’s Better Care Everywhere webinar series, Dr Hayes says there is a large variation in opioid prescriptions dispensed that is ‘unrelated to the patients themselves and more related to the prescriber and their beliefs and habits of prescription.’
He says the Commission’s Third Australian Atlas of Healthcare Variation (2018) showed that the rate of Pharmaceutical Benefits Scheme (PBS) prescriptions for opioids dispensed per 100,000 people had increased by 5% in the four years to 2016-17. And the magnitude of variation had also increased, rising from a 4.8-fold difference between the local areas with the highest and lowest rates in 2013-14 to 5.1-fold in 2016-17.
Five key messages for clinicians:
- Don’t start. With clear evidence that opioids are ineffective for chronic non-cancer pain, Dr Stevens says ‘don’t start people down that road’.
- Cessation plan. When opioids are started in hospitals for acute pain, Dr Hayes says it is important to agree upon a clear cessation plan with the patient, and to share that plan with the patient’s GP.
Also, he says, any opioids prescribed at discharge should be based on the patient’s dose in the previous 24 hours. ‘In the hospital system, we have often been guilty of giving patients a standard pack of 20 Endone tablets, for example, when they have used no opioids at all in the [previous] 24 hours,’ he says. - Individualise discussions about side effects. When talking to patients about opioid harms, Dr Stevens suggests that clinicians highlight the side effects that are most relevant to the individual. For example, she says, a patient who has experienced depression might be less likely to take opioids if they knew that these drugs might make their depression ‘treatment resistant or worse’.
- Debunking the ‘coverage’ myth. Opioids are sometimes prescribed to give patients ‘coverage’ for night-time pain relief, but Dr Stevens says this is ineffective and results in the ‘maximal development of tolerance and associated problems.’
- Wean with kindness. It is important not to ‘demonise’ patients who have been using opioids long term, Dr Stevens says. ‘Most patients didn’t ask for opioids, and many have a history of anxiety and depression,’ she says. ‘Our approach to this group should be driven by empathy and safety.’
When weaning patients off opioids, Dr Hayes says a ‘shared decision-making’ approach is most effective. He recommends a monthly step-down by 10-25% of the starting dose, noting some patients may require faster or slower rates of reduction.
Managing pain without opioids
Dr Hayes, who is also the Director of the Hunter Integrated Pain Service (HIPS) at John Hunter Hospital, says HIPS promotes a whole-person approach to pain management encompassing five elements: biomedical, mind-body, connection, activity and nutrition.
He says while opioids are one small component of the biomedical approach, there are other, evidence-based treatment options for chronic pain that have a greater chance of bringing long-term pain reduction and, perhaps, resolution’.
Dr Stevens agrees, and says that a more holistic approach to pain management in her hospital and in the local community has been beneficial to all.
For osteoarthritis, for example, Dr Stevens says increasing activity and decreasing weight, as well as increasing social connectivity and a focus on mental health, has been shown to be effective.
Regulatory shifts
Regulatory changes are also helping to stem the tide of opioid prescribing for chronic non-cancer pain.
Dr Hayes says a range of initiatives, including the Therapeutic Goods Administration’s (TGA) 2020 statement that modified release opioids are ‘no longer indicated for use in chronic non cancer pain other than in exceptional circumstances’ and last year’s Pharmaceutical Benefits Scheme changes, are encouraging improved prescribing opioids practices.
Most pain management guidelines also discourage the use of opioids for chronic non-cancer pain, says Dr Hayes, pointing to the HIPS statement released last year.
Dr Hayes says both the primary care and hospital sectors have contributed to the over-prescribing of opioids for non-cancer chronic pain.
‘There is a responsibility in both of those sectors for us to do things differently.’