ED: Patients becoming dependent on opioids is a situation everyone tries to avoid. What are the alternatives?
The WHO’s 1986 pain ladder depicted a three-step process to treat pain starting with non-opioid analgesics (NSAID’s, paracetamol), then weak opioids (codeine, tramadol), then strong opioids (hydromorphone, oxycodone, fentanyl). This was intended to improve control of cancer pain, which was and is limited in many areas of the world.
Understanding the context
Although designed for cancer pain, it has been interpreted as a three-step protocol for general mild, moderate and severe pain. This became the basis of treatment for many acute pain services in the 1990s, with great success for post-surgical pain.
Encouraged by this success, opioids have been increasingly used for severe chronic pain. This has led to a first world opioid epidemic and increasing toll of human lives from unintended prescription drug (mainly oxycodone and fentanyl) deaths. In Australia, opioids were responsible for over 1100 deaths per year, having tripled in a little over fifteen years.
This leaves practitioners in a very difficult situation. Chronic pain is very common, and often starts from an acute episode which responds well to opioids. What starts as an effective treatment leads to tolerance, dose escalation and increasing harm to the patient, including a paradoxical worsening of pain (opioid induced hyperalgesia) and, death.
Managing persistent pain
When a pain is persistent, the focus needs to change from just increasing opioids.
A graded approach based on SAFE principles is an alternative approach that balances risk and benefit.
Firstly, review medically, including all analgesics and integrate with a team based approach. Paracetamol is often ineffective but if there is a benefit, keep below 4g/day. NSAID’s – Celecoxib (if effective for that patient) has a good safety profile for longer term use. Discontinue if not helping pain.
If opioids are used, avoid where possible opioids associated with increasing numbers of deaths (oxycodone, fentanyl in particular). Atypical opioids such as tapentadol and tramadol have antineuropathic effects, mostly due to noradrenergic reuptake inhibition, and have been less associated with opioid related deaths.
Keep opioid doses below 90 mg/day of morphine equivalent as per WA health guidelines. If the pain has neuropathic qualities (burning/electric shock/painful cold) then antineuropathic agents (gabapentinoids, serotonin/nor-adrenaline reuptake inhibitors or low dose tricyclic antidepressants) can also be trialled. They all carry significant side effects but can provide substantial pain improvement with neuropathic pain.
Review allied health input; physiotherapy/exercise physiology to restore and/or maintain function. Teach pacing strategies to avoid boom/bust type behaviours. Clinical psychology review to learn coping strategies for persistent pain anxiety management.
Physical interventions
If the above is not helping, minimally invasive options are targeted lower risk procedures that include: joint and nerve blocks and steroid injections, neurotomy/rhizotomy, Botox/ketamine infusion/lignocaine infusions.
Procedural interventions are generally low risk and especially suited to the elderly not tolerating medical therapies. They can provide low risk alternatives in a number of areas. Geniculate nerve rhizotomy for knee osteoarthritis provides an alternative for the elderly patient who might not tolerate arthroplasty.
Consider major interventions when other measures have failed. For example, joint arthroplasty, or carefully selected back surgery for radicular pain. For axial back pain without radiation, and several other pain conditions, neuromodulation has high level evidence of its efficacy.
The non-responders
A group remains who do not respond within standard risk-benefit guidelines. Attempts to “fix” their pain, while well intentioned, have led to a rising number of deaths from high dose opioids. Use caution and fully inform patients of risks before using a treatment that lacks strong evidence base.
Non-responders will understandably be searching for new treatments, and often find them. These include various off-label medications, cannabinoids, and procedures not well established. Pain is important and it is unlikely there will ever be a single “cure” that works for everyone. For non-responders, our role is to explain the risks, to expand the evidence for new treatments, and avoid doing more harm than good with well-meaning intentions.
Key Messages
- Opioids have role in cancer and acute pain but are associated with increasing mortality in higher doses.
- Chronic pain requires multidisciplinary assessment.
- Targeted medications and procedural interventions all have a role.
References available on request.
Questions? Contact the editor.
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