Opioids, chronic pain and the bigger picture

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Description

RACGP 2017

Prescribing drugs of dependence in general practice, Part C1: Opioids

This guide aims to help general practitioners (GPs) prescribe opioids appropriately in the general practice context.

It is designed to discourage inappropriate use and reduce harms by providing GPs with guidance and practical advice regarding opioid therapy.

It is complemented by Part C2: The role of opioids in pain management and aligns with Prescribing drugs of dependence in general practice, Part A: Clinical governance framework.

Prescribing drugs of dependence in general practice, Part C2: The role of opioids in pain management

This guide is designed to assist with the appropriate and accountable prescribing of analgesic medications in the general practice context. Used in combination with Prescribing drugs of dependence in general practice, Part C1: Opioids, it is designed to discourage inappropriate use and reduce harms of opioids. It provides GPs with evidence-based guidance and practical advice on pain and pain management. In particular, this guide provides recommendations for GPs who are prescribing opioids for acute and chronic pain outside of active cancer treatment, palliative care, and end-of-life care.

Faculty of Pain Medicine. Australian and New Zealand College of Anaesthetists (ANZCA) 2015

Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain.

This concise document outlines the position of the FPM on opioid use in chronic non-cancer pain. It reviews the evidence (up to time of publication) and presents principles and practical advice for opioid prescribing.

NSW Agency for Clinical Innovation (ACI) 2019

Quick steps to manage chronic pain in primary care. Pain management network

The most recent Australian opioid guideline. It is a brief guide that provides easily understood information on initiating, continuing and reducing opioids.

Busse et al. 2017

Guideline for opioid therapy and chronic noncancer pain

These are comprehensive guidelines on the use of opioids in chronic non-cancer pain, published by the CMAJ.

The CMAJ has also developed the MAGICapp website that contains guideline recommendations, best practice statements and expert guidance.

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Description

Juurlink. 2017

Rethinking “doing well” on chronic opioid therapy.

This paper articulately reframes the use of opioid therapy in chronic non-cancer pain and argues for a more cautious approach to the use of opioids.

Dowell and Haegerich. 2017

Changing the conversation about opioid tapering. 

Provides a short commentary on tapering including risks/benefits and practical strategies for patients having challenges with tapering.

Busse et al, 2018

Opioids for chronic noncancer pain: a systematic review and meta-analysis

A meta-analysis of 96 RCTs (n=26,169) of patients with chronic non-cancer pain, which found that for most patients, opioids do not provide clinically important improvement in pain or function compared with placebo. Evidence from RCTs shows that use of opioids compared with placebo was associated with statistically significant but small improvements in pain (−0.69 cm on a 10 cm scale, less than the minimally important difference of 1 cm) and physical functioning (2.04 of 100 points, less than the minimally important difference of 5 points).

Opioids were associated with less pain relief during longer trials which may be a result of opioid tolerance or opioid-induced hyperalgesia. The authors suggest a reduced association with benefit over time might lead to prescription of higher opioid doses and consequent harms.

In the 6 RCTs that compared different doses of opioids, meta-regression of moderate-quality evidence showed no dose response for pain relief (p=0.39), functional recovery (p=0.22), or gastrointestinal adverse events (p=0.12).

Krebs et al, 2018

Effect of opioid vs non opioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial.

This long-term randomised clinical trial concluded that treatment with opioids alone was not superior to treatment with various combinations of non-opioid medications for improving pain-related function over 12 months.

Of the 234 randomised patients who completed the trial, there was no statistically significant difference between opioid and non-opioid groups on pain-related function over 12 months (overall p=0.58). Pain intensity was significantly better in the non-opioid group over 12 months (overall p=0.03). Adverse medication-related symptoms were significantly more common in the opioid group over 12 months (overall p=0.03).

Results do not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.

Chou et al, 2015

The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop.

This systematic review evaluates evidence on the effectiveness and harms of long term (> 3 months) opioid therapy for chronic pain in adults.

Evidence is limited, but accumulating data suggests that opioid treatment for chronic pain is associated with increased risk for serious harms. These include overdose, opioid misuse, fractures, myocardial infarction, and markers of sexual dysfunction; for some harms, the risk seems to be dose-dependent.

Mazereeuw et al, 2018

Mazereeuw et al 2018. Depression in chronic pain: might opioids be responsible?

Emerging evidence suggests an association between opioids and depression.

The paper describes a dose-dependent association between opioids and depression, particularly with prolonged use. There is some data to suggest that initiation of opioid therapy is associated with failure of first-line antidepressant interventions. Additionally, opioid dose reduction may improve depressive symptoms.

The authors suggest clinicians consider a cautious, gradual taper under close medical supervision for patients with depression on long-term opioid therapy.

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Reference

Results and recommendations

Frank et al, 2017

Patient outcomes in dose reduction or discontinuation of long-term opioid therapy: a systematic review

This systematic review synthesises study findings on the effectiveness of strategies to reduce or discontinue long-term opioid therapy, and patient outcomes after dose reduction.

Very low-quality evidence suggests that several types of interventions – including interdisciplinary pain programs, behavioural interventions and buprenorphine-assisted dose reduction – may be effective to reduce or discontinue long-term opioid therapy. Pain, function, and quality of life may improve with opioid dose reduction.

Fishbain and Pulikal, 2018

Does opioid tapering in chronic pain patients result in improved pain or same pain vs increased pain at taper completion? A structured evidence-based systematic review.

The results of this systematic review confirm the hypothesis that opioid tapering for patients with chronic pain improves pain or maintains the same pain level by taper completion but does not increase pain.

As patients are fearful of increased pain as a result of discontinuing opioids, these findings may help clinicians provide reassurance about opioid tapering.

Matthias et al, 2017

“I’m not gonna pull the rug out from under you”: patient-provider communication about opioid tapering.

Communicating about tapering can be difficult, particularly with patients receiving long-term opioids who perceive benefits and are using their medications as prescribed. This study identifies best practices and opportunities for improvement in communication. The study concludes that although opioid tapering can be challenging, helping patients to understand individualised reasons for tapering, encouraging patients to have input into the process, and assuring patients they will not be abandoned all appear to facilitate better communication about tapering.

Khoo et al, 2019

Comparative evaluation of group-based mindfulness-based stress reduction and cognitive behavioural therapy for the treatment and management of chronic pain: A systematic review and network meta-analysis

A systematic review and network meta-analysis that compared mindfulness-based stress reduction (MBSR) to cognitive behavioural therapy (CBT) against control conditions for patients with chronic pain (n=1981). Clinically important advantages were found in physical functioning, pain intensity and depression for both therapies and there was no significant difference between the two.

The authors concluded that while CBT is the preferred psychological intervention for patients with chronic pain, not all patients with chronic pain experience a clinically significant treatment response. MBSR presents an additional solution for improving pain severity and reducing pain interference and psychological distress.

Williams et al, 2012

Psychological therapies for the management of chronic pain (excluding headache) in adults (Review)

This Cochrane review analysed data from 35 studies (n=4788) and compared two main classes of treatment; cognitive behaviour therapy (CBT) and behaviour therapy with control conditions. The authors found that CBT is a useful approach to the management of chronic pain.

CBT has weak effects in improving pain immediately post-treatment, when compared with treatment as usual/waiting list. CBT has small effects on disability associated with chronic pain, with some maintenance at 6 months. CBT is effective in altering mood and catastrophising outcomes, with some evidence that this is maintained at 6 months.

Behaviour therapy has no effects on mood but showed an effect on catastrophising immediately post-treatment.

Veehof, et al, 2016

Acceptance- and mindfulness-based interventions for the treatment of chronic pain: a meta-analytic review

A meta-analysis of 25 RCTs (n=1285) that concluded that acceptance- and mindfulness-based interventions for chronic pain have small effects on pain intensity, depression, disability and quality of life, and moderate effects for anxiety and pain-interference.

Acceptance and commitment therapy (ACT) showed significantly higher effects on depression and anxiety in individuals with chronic pain than mindfulness-based stress reduction (MBSR) and mindfulness-based cognitive therapy (MBCT).