Pain is famously subjective. Opium products have been used for millennia to treat pain. While pharmaceutical opioids remain essential in treating acute pain, concerns have arisen around the safety and efficacy of opioids in treating chronic, non-cancer pain. Drug therapy for pain aims to control symptoms enough to reduce distress and restore function, while minimising the potential for adverse outcomes. Judicious prescribing involves balancing risks and benefits. Coupled with non-drug therapies, appropriate medication greatly improves quality of life for the patient.2
An estimated 20% of Australians suffer chronic pain. Chronic pain is multidimensional, affecting all aspects of someone’s life and conversely, many aspects of someone’s life can affect the perception of pain and ability to function. Pain is perhaps best understood, and treated, as a complex socio-psycho-biomedical issue. These complexities multiply when someone is dependent upon opioids, or appears to have developed addictive patterns of behaviour.
Prescribing concerns centre around accidental overdose, diversion or misuse, and initiating an iatrogenic Opioid Use Disorder (OUD). Given these challenges, what can the physician do? Here are three simple tips from a consumer perspective…
“Both deception and fear of deception have consequences. Patients can get too much medical care when the doctor is deceived… or insufficient medical care when the doctor fears deception… These consequences affect both the individual patient and society”. Beth Jung 1
1) Don’t make assumptions.
An opioid dependent person needs higher doses to treat episodes of acute pain3, (due to cross-tolerance and opioid-induced hyperalgesia), yet people engaged in opioid substitution therapy typically receive suboptimal treatment following injury or surgery, due to misconceptions of health providers. 4
Screening for risk of opioid misuse is widely recommended; however screening for high-risk patients, treatment agreements and urine testing have not been shown to reduce overall rates of opioid misuse or overdose.5
Many physicians are confident they can identify patients who misuse opioid medications, yet research shows that doctors only identify 10% of ‘sham’ patients, while misidentifying a proportion of genuine patients as ‘shams’.1
Chronic opioid treatment will often lead to physical dependency6, but most patients will not develop an OUD. Research finds that only 5% 7 to 6% 8 of patients treated with opioid analgesic therapy progress to meet diagnostic criteria for opioid misuse or abuse. While further research is needed, the risk appears to follow a U-shaped curve; inadequate7 or excessive8 treatment can both increase risk.
While there are obvious risks associated with inappropriately liberal prescription of opioids, there are also risks associated when pain is not adequately addressed in patients who have a previous history of chronic opioid therapy or of illicit opioid use. Failure to engage effectively with these people increases the risk of them misusing prescribed medication, or of resorting to self-medication with diverted or illicit opioids. Apparent “drug-seeking” may actually be “pain-relief seeking” behaviour9. People with a previous history of misuse may relapse if genuine pain needs are dismissed or neglected by their doctor.
2) Manage withdrawal from opioids, and transition to non-opioid medications, sensitively.
Ideally, withdrawal from chronic, high dose opioid regimes should be managed carefully, with a gradual reduction regime, the option of stable periods between reductions to allow acclimatisation to the lower dose, and a gentle taper before final cessation. When referring a patient to a Pain or Addiction Medicine specialist be aware that most have wait lists and you will need to ensure their pain is managed appropriately until they are properly assessed for specialist treatment. In the meantime, try to use counselling and psychosocial supports.
3) Express genuine empathy, clearly explain the rationale behind treatment changes, and engage the patient in planning.
Pain patients frequently report high levels of distress and dysfunction when doses are reduced with little or no consultation. Anxiety and depression are common, as are feelings of being judged. Clear communication and reassurance from a supportive physician can alleviate this. State your concerns and involve the patient in planning a manageable reduction. Acknowledge their symptoms, and be prepared to modify the plan to manage them. If your patient trusts (and feels trusted by) you, and if they feel their concerns are being taken seriously, you can mitigate risks while working in partnership to help them achieve the best quality of life possible.
1 Jung & Reidenberg 2007
Physicians Being Deceived. Pain Medicine, Volume 8, Issue 5, 1 July 2007, Pages 433–437, https://doi.org/10.1111/j.1526-4637.2007.00315.x
2 Recommendations regarding the use of Opioid Analgesics in patients with chronic Non-Cancer Pain, 2015. http://fpm.anzca.edu.au/documents/pm1-2010
3 ANZCA Working Group Faculty of Pain Medicine. Acute Pain Management 2015: http://fpm.anzca.edu.au/documents/apmse4_2015_final See 10.6 The opioid-tolerant patient and 10.7 The patient with an addiction
4 Alford et al 2006. Acute Pain Management for Patients Receiving Maintenance Methadone or Buprenorphine Therapy Published: Ann Intern Med. 2006;144(2):127-134. DOI: 10.7326/0003-4819-144-2-200601170-00010 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1892816/
5 Devo et al 2015. Opioids for low back pain. BMJ. 2015 Jan 5;350:g6380. doi: 10.1136/bmj.g6380https://www.ncbi.nlm.nih.gov/pubmed/25561513
6 Hartman H 2015. Risk factors for iatrogenic opioid dependence: An Australian perspective. AMSJ Dec 2015 http://www.amsj.org/archives/4445
7 Higgins et al 2018. Incidence of iatrogenic opioid dependence or abuse in patients with pain who were exposed to opioid analgesic therapy: a systematic review and meta-analysis. British Journal of Anaesthesia, 120 (6): 1335-1344 (2018) https://doi.org/10.1016/j.bja.2018.03.009
8 Edlund et al 2015. The Role of Opioid Prescription in Incident Opioid Abuse and Dependence Among Individuals with Chronic Non-Cancer Pain: The Role of Opioid Prescription. Clin J Pain. 2014 Jul; 30(7): 557–564. DOI: 10.1097/AJP.0000000000000021
9 Weissman & Haddox 1989. Opioid pseudoaddiction–an iatrogenic syndrome. Pain. 36(3):363-6, MAR 1989 PMID: 2710565 https://www.ncbi.nlm.nih.gov/pubmed/2710565