Persistent pain is common, affecting around five million people in the UK. For many sufferers, pain can be frustrating and disabling, resulting in functional impairment - physically, emotionally and vocationally. Medications and other treatments that aim to reduce pain intensity play a role in the management of symptoms, but should be provided as part of a wider management plan focused on reducing disability and improving overall quality of life.
Opioids have been increasingly prescribed to treat chronic non-malignant pain. There is evidence from clinical trials that they can be effective, in the short and medium term, in providing symptomatic improvement in somatic, visceral and neuropathic pain. Complete relief of pain is rarely achieved. The goal should be to reduce pain sufficiently to facilitate engagement with rehabilitation and the restoration of useful function. The management of persistent pain focuses not only on reduction in pain intensity but also on improvement in sleep, mood, and physical, vocational, social and emotional wellbeing.
The safety and efficacy of opioids in the long term is uncertain, as is the propensity for these drugs to cause problems of tolerance, dependence and addiction. The benefits of opioid treatment for the patient must be balanced against burdens of long term use as therapy for persistent pain may need to be continued for months or years.
There is no good predictive factor of the analgesic effect of opioids in chronic non-malignant pain. If deemed appropriate, the individual should have a monitored opioid trial over a period of 6 weeks to determine the effectiveness of the treatment and the presence of side effects. If the clinical decision is made to continue the prescription of the opioid, there should be ongoing timely reassessment.
Recommendations are made on determining the suitability of an opioid trial, the choice of opioid, the conduct of an opioid trial and long term monitoring of the patient.
The guidelines reviewed included the following:
- The British Pain Society (2010)
- Sign 136 – Management of Chronic Pain (Dec 2013)
- U.S. Department of Veterans Affairs/Department of Defence (2010)
- The Canadian Guidance (2010)
- Guidelines for South Australian GPs (2009)
- American Pain Society-American Academy of Pain Medicine (APS-AAPM) Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain (2009)