The management of chronic non-cancer pain (CNCP) remains a significant challenge in healthcare. While opioids are often considered for pain relief, their use requires careful consideration due to potential risks, side effects and potential harm. This article explores best practices in opioid use for CNCP, the risks associated with co-prescription of benzodiazepines, and the importance of a multi-disciplinary approach to pain management.
Guidelines for best practices
The use of opioids for CNCP should follow specific guidelines to ensure patient safety and effective pain management. Firstly, opioids are considered only after other non-opioid treatments have been explored and found ineffective. There is a lack of high-quality evidence to support efficacy of opioids in CNCP.
When prescribed, the lowest effective dose should be used, and the patient’s pain and function regularly monitored. Dose titration should be based on clear functional benefit and risk of harm, with higher dose and longer duration of treatment considered. Appropriate time between dose titration is recommended to avoid potential risks such as sedation and respiratory depression.
Particular caution should be exercised for patients with renal impairment, liver dysfunction, elderly or patients with low body mass index. Medication selection should include partial mu-agonists, such as tramadol, tapentadol or buprenorphine as opposed to full mu-agonists, where appropriate.
Healthcare providers should also screen patients for risk factors such as a history of substance abuse, personality and mental health disorders before initiating opioid therapy. Appropriate adjustment in treatment and involvement of other specialists should be considered. Regular follow-up and reassessment are crucial to evaluate the benefits and harms of continued opioid use, consider referral to a pain specialist. Patients should also be educated about the risks, potential side effects, and safe storage and disposal of opioids.
Benzodiazepine co-prescription: understanding the risks
Co-prescribing benzodiazepines, or benzodiazepine-like-medications, with opioids significantly increases the risk of adverse events, including overdose. Benzodiazepines have sedative effects like opioids, and can depress the central nervous system, leading to respiratory depression, particularly when combined.
Benzodiazepines are generally not well evidenced in chronic pain management, with exception of specific conditions such as spasticity secondary to central nervous system injury/disease. Consider neurological specialist physiotherapy review if a patient presents with spasticity to ascertain degree of functional impairment and optimisation of non-pharmacological management.
Healthcare providers should exercise extreme caution and consider alternative treatments for anxiety or insomnia in patients receiving opioid therapy. Consider involvement of a psychiatrist. If co-prescription is unavoidable, it should be at the lowest possible doses and for the shortest duration, with close monitoring for signs of sedation and respiratory depression.
Multidisciplinary pain management
Effective management of CNCP often requires a multidisciplinary approach, integrating various modalities to address the physical, emotional, and psychological aspects of pain. This approach can include physical therapy, psychology (e.g. cognitive-behavioural therapy), occupational therapy, and interventional management from pain specialists. Non-pharmacological treatments such as acupuncture, biofeedback, transcutaneous electrical nerve stimulation can also be beneficial in certain patients.
This holistic approach aims to improve the patient’s overall quality of life, reduce reliance on medications, and address underlying factors contributing to the pain. Additionally, involving a multidisciplinary pain team can facilitate more informed decision-making about opioid use and help identify when it’s appropriate to taper or discontinue opioid therapy. When used, opioids should ideally be time limited and prescribed to facilitate participation in rehabilitation and physical therapies.
Managing chronic non-cancer pain with opioids requires a judicious, patient-cantered approach. Adhering to best practice guidelines, being cautious about co-prescribing benzodiazepines, and employing a multidisciplinary strategy are critical for safe and effective pain management. By balancing these aspects, healthcare providers can offer the most beneficial care to individuals suffering from CNCP, enhancing their quality of life while minimising potential risks associated with opioid therapy.
Key messages
- The management of chronic non-cancer pain remains a significant challenge in healthcare.
- While opioids are often considered for pain relief, their use requires careful consideration due to potential risks and side effects.
- Healthcare providers should screen patients for risk factors before initiating opioid therapy and consider alternative treatments for anxiety or insomnia in patients receiving opioid therapy.
Author competing interests – nil