Opioid prescribing for chronic noncancer pain in general practice

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Pain management in the general practice setting often defaults to the use of analgesic drugs, frequently opioids. This short article applies guideline recommendations that could be used by General Practitioners in prescribing opioids for people with chronic noncancer pain (CNCP).

Article by Simon Van Rysewyk, PhD; Associate Director (Medical Writing) at EPG Health

Biopsychosocial assessment of chronic pain

CNCP has biological, psychological, and social roots, each of which the General Practitioner (GP) should assess^1–6.

Non-pharmacological treatments for CNCP include explaining and advising on exercise, sleep, nutrition, and encouraging the person with CNCP to undertake personally meaningful activities^1–7.

Pharmacological management for people with CNCP is part of multidisciplinary care. If medications are needed, the GP should also assess psychological and social contributors^1–7.

Nonopioid analgesics are an option for symptom control in CNCP. They include paracetamol, or ‘adjuvants’, such as tricyclic antidepressants (amitriptyline, nortriptyline), serotonin or noradrenaline reuptake inhibitors (duloxetine, venlafaxine), or anticonvulsants (gabapentin, pregabalin)^1–7.

Invasive treatments, including injections or implants, may not be considered by the patient or physician as a treatment option, especially when evidence of pathology is lacking. Opioid analgesics should be considered prior to invasive treatments^1–7.

Opioid trial agreement

A written ‘opioid trial agreement’ should be made between the prescriber and patient, stipulating^2,6,8:

• Realistic, personalised goals, that improve function and comfort
• One prescriber and one pharmacy dispensing, based on risk assessment (no early repeat prescriptions or loss replacements)
• Review intervals (up to third-monthly for stable patients)
• If treatment goals are not met, tapering dose to termination of the opioid trial
• Serious adverse outcomes, or evidence of misuse or unsanctioned use (self-injection, stockpiling, selling, or giving drugs to others)
• Random drug monitoring (urine drug screen or pill counts)

Continuing prescription is conditional on evidence of ongoing benefit and minimal harm^2,6,8.

Opioid trial

Opioid analgesics for people with chronic noncancer pain is an ongoing trial of therapy

The focus of the opioid trial is on improved function and reduced discomfort^2,6,8.

The pharmacological principle of an opioid trial is use of long-acting oral, or transdermal opioid analgesics, dosing according to patient age. The starting dose should be low if the person with CNCP is opioid naïve (10 mg daily oral morphine equivalent). If the patient is already taking an immediate-release opioid, such as codeine, morphine, or oxycodone, calculate the daily dose using an equianalgesic chart to convert it to an approximate daily equivalent of a long-acting oral or transdermal preparation^1–7. Regularly reassess the patient, weekly initially, then according to achievement of goals, according to the ‘5A criteria’^1–7:

• Analgesia
• Activity
• Adverse effects
• Affect
• Aberrant behaviour

Titration of dose according to the 5A assessment should allow the basic question, ‘Is this person’s situation opioid-responsive?’, to be answered. A decision can then be made to continue maintenance therapy, conditional on ongoing satisfactory 5A assessment, test the effects of dose reduction, or taper to withdrawal.

The drug regimen should be adapted to the patient’s needs, such as taking the drug at night to improve sleep, or varying the dose during the day based on activity levels. Limit the dose to a maximum of 100 mg daily oral morphine equivalent. An apparent opioid requirement approaching this should prompt reassessment. If tapering of opioid therapy is required, the rate is to reduce the daily dose by 10% per week^1–7.

Difficulty achieving the opioid trial goals

The main difficulties that confront an opioid trial are1–7:

• Increased function, but no change in pain
• Unsanctioned drug use

If the patient has increased function, but no change in pain, the patient may need to monitor and adjust his or her ‘activity pacing’^1–7.

In case of unsanctioned opioid use, the opioid should be tapered to withdrawal, and the patient referred to a pain or addiction medicine specialist^1–7.

When the trial goals are not achieved due to a change in the patient’s life situation, a new opioid agreement can be negotiated, with revised goals and review plans. Conduct a new biopsychosocial assessment, and ask the basic question above^1–7.

If in doubt about the opioid trial, consult with a colleague, a pain, or addiction medicine specialist.

Learn more on Medthority’s Neuroscience and Pain Specialty Hub and Disease Page

References

1. Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, et al. Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. J Pain. 2009;10(2):113-130.e22.
2. The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice. 2020 Available at: https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/drugs-of-dependence. Accessed 8 January 2022.
3. National Institute for Healthcare and Clinical Excellence. Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. NICE Guidelines. 2021;(April):NICE guideline [NG193].
4. Häuser W, Morlion B, Vowles KE, Bannister K, Buchser E, Casale R, et al. European clinical practice recommendations on opioids for chronic noncancer pain – Part 1: Role of opioids in the management of chronic noncancer pain. Eur J Pain. 2021;25(5):949–968.
5. Krčevski Škvarč N, Morlion B, Vowles KE, Bannister K, Buchsner E, Casale R, et al. European clinical practice recommendations on opioids for chronic noncancer pain – Part 2: Special situations. Eur J Pain (United Kingdom). 2021;25(5):969–985.
6. Faculty of Pain Medicine. Australian and New Zealand College of Anaestheists. Statement regarding the use of opioid analgesics in patients with chronic non-cancer pain. 2021 www.fpm.anzca.edu.au/documents/opioid-dose-. Accessed 12 January 2022.
7. Busse JW, Craigie S, Juurlink DN, Buckley DN, Li W, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659–E666.
8. Asamoah-Boaheng M, Badejo OA, Bell L V., Buckley N, Busse JW, Campbell TS, et al. Interventions to Influence Opioid Prescribing Practices for Chronic Noncancer Pain: A Systematic Review and Meta-Analysis. Am J Prev Med. 2021;60(1):e15–e26.