Opioid medication has potential benefits for patients in pain but there are significant risks of narcotic side effects especially with high doses.
Furthermore, not all narcotics are created equal and some have a markedly higher propensity to cause problems, such as addiction etc.. Opioid addicted patients represent a high risk group for complaints – careful documentation is imperative and an opioid contract desirable.
Chronic opioid therapy in non-cancer pain has been addressed extensively by the American Pain Society, with guidelines developed. One conclusion made was there is no evidence for long-term treatment with opioids – studies have not addressed endpoints for treatment, with no firm evidence supporting opioid medication in patients with chronic non-cancer pain. Evidence is emerging of the costs of being on narcotics, particularly increased unexplained deaths in patients on opioids (especially higher doses).
Addiction and drug related behaviour
No studies adequately address the cost effectiveness of opioids for non-cancer pain. The American Pain Society focuses on minimising doses and avoidance of high-dose opioids. Similarly, guidelines of the Australian College of Anaesthetists (Pain Section) reflect ongoing concern with opioids.
It is very common to find relatively functional patients with significant physical and psychological dependency on medications.
Some opioids are a higher risk than others. Oxycodone and fentanyl constitute opioids with a higher potential for dependence, addiction and ultimately abuse. Diversion is a problem with addicts extracting opioid out of the fentanyl patches, either for injection or simply chewing or eating the patch. Oxycodone, even though reformulation has reduced the chances of injection, is still regularly injected and there is controversy about how much is diverted.
My view is these medications should be reserved for acute pain and not extrapolated to chronic pain. Targin SR in very small doses may be appropriate in the elderly with crush fractures who are predisposed to constipation etc. but mostly, oxycodone should be taken out of the arena for chronic pain (as happens with fentanyl patches). There have been a number of deaths examined by the Coroner of WA over fentanyl patch use.
Ideally, people on these medications (fentanyl and oxycodone) should be referred to a pain management specialist or a pain clinic where steps can be taken to change them onto some other medication.
Morphine also presents concerns for chronic use, with morphine elixir noted to increase abuse. In my view, morphine elixir should not be used for chronic pain. In the past, patients commenced because “they couldn’t tolerate tablets” but better options now mean this is no longer a valid reason for prescribing morphine elixir in chronic pain.
Choosing wisely
Better narcotics e.g. Palexia in a SR preparation, means that opioids are now available with significantly less risk of addiction. In recognition of the lower propensity for addiction with patients on tapentadol (Palexia) the Health Department will allow use by GPs as a sole opioid in most dose ranges, without Specialist approval.
Tramadol presents another option, although many patients experience significant nausea. Buprenorphine, as patches, has a low propensity to addiction and should be favoured over other more addictive opioids. Physeptone is another option and has less addictive potential for those not easily controlled by weaker opioids. Failing this hydromorphone SR could be used.
Some practitioners have had legal action against them by individuals “addicted” to opioids. The prevailing evidence is against using strong opioids for chronic non-cancer pain. I envisage it will become indefensible for a general practitioner to commence patients on stronger narcotics without an extensive trial of tramadol, tapentadol or buprenorphine first. Wherever possible oxycodone, fentanyl and morphine should be avoided.
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