In January 2010, the British Pain Society in collaboration with the Faculty of Pain Medicine of the Royal College of Anaesthetists, the Royal College of General Practitioners and the Faculty of Addictions of the Royal College of Psychiatrists published revised best practice guidance for the use of opioids in persistent pain. As the evidence base in many aspects was, and still is, rather limited many of the recommendations are derived from expert consensus.
Full guidance for prescribers is available on the BPS website (http://www.britishpainsociety.org/book_opioid_main.pdf). In addition, a summary A4 version which may be more suited to wider dissemination to non-specialists is available (http://www.britishpainsociety.org/book_opioids_recommendations.pdf). As with all BPS publications there is summary written for patients too (http://www.britishpainsociety.org/book_opioid_patient.pdf).
The executive summary to Opioids for persistent pain: good practice is reproduced below.
The guidance applies to all opioids available in the UK.
The guidance does not include recommendations on the use of spinally delivered opioids.
Opioids are traditionally classified as strong or weak. This guidance does not apply to patients who use weak opioids within the BNF dose range, but supports prescribing for patients who use weak opioids outside the BNF range and for patients who might benefit from using strong opioids.
Opioids are prescribed to reduce pain intensity. Data demonstrating sustained analgesic efficacy in the long term are lacking.
Complete relief of pain is rarely achieved with opioids. The goal of therapy should be to reduce symptoms sufficiently to support improvement in physical, social and emotional functioning.
80% of patients taking opioids will experience at least one adverse effect. These should be discussed with the patient before treatment begins.
Patients taking appropriate doses of prescribed opioids are permitted by law to drive in the UK if they are using no more than the prescribed dose and feel fit to drive. Patients should be advised to avoid driving at the start of opioid therapy and following dose changes. Patients should be informed that it is their responsibility to advise the DVLA that they are taking opioid medication.
Patients must be aware of uncertainty regarding the long term effects of opioids, particularly in relation to endocrine and immune function.
Opioids should not be used as first line pain therapy if other evidence-based interventions are available for the condition being treated.
The decision to start long term opioid therapy should be considered carefully by the prescriber, the patient and his/her carers and other members of the healthcare team. Arrangements for long-term monitoring and follow-up must be in place.
There is no right or wrong sort of patient for opioid therapy. Assessment of the patient in pain should include a history of the patient’s mental health, in particular screening questions for depression and substance misuse disorders. This is especially important when prescribing opioids for persistent pain.
Where possible, modified release opioids administered at regular intervals should be used in the management of patients with persistent pain. Use of more flexible dosing regimens using immediate release preparations (alone or in combination with modified release preparations) may be justified in some circumstances.
Injectable opioids should not be used for the management of persistent pain.
Patients being considered for long term treatment with opioids should have a carefully supervised trial of opioid therapy with evaluation of analgesic efficacy and adverse effects.
If patients do not achieve useful relief of pain when titrated to doses between 120 and 180 mg morphine equivalent per 24 hours, referral to a specialist in pain medicine is strongly recommended.
The prescription of opioids can result in problem drug use. The likelihood of this occurring might be influenced by a number of social, psychological and health related factors.
Concerns about problem drug use should prompt referral to specialised pain and addiction services.
Patients with a current or past history of substance misuse or with a comorbid non-substance misuse psychiatric diagnosis may be more likely to develop problems with opioid use. Opioid treatment for these patients should be closely and collaboratively monitored by specialists in pain management and/or addiction medicine.
Opioids for persistent pain: Good practice
Available from http://www.britishpainsociety.org/pub_professional.htm#opioids