Feature
Examining the role of prescription opioids for chronic non-cancer pain
With codeine up-scheduling coming from 1 February, many in the medical profession are debating the question of whether opioids should ever be used in the management of chronic non-cancer pain.
It is recommended that any use of opioids in managing chronic non-cancer pain be closely monitored.
The growth of opioid overuse in Australia have been widely documented, leading to efforts by the medical community to reduce prescriptions of opioids and the up-scheduling of codeine by the Therapeutic Goods Administration (TGA). Against this background, some doctors believe that opioids should have no treatment role outside the treatment of cancer pain and palliative care.
But not all agree with such a hard-line approach. Dr Evan Ackermann, GP and leading contributor to the RACGP’s Prescribing drugs of dependence in general practice: Part C, argues that opioids can have a role in the management of chronic non-cancer pain, albeit one that is restricted and requires assessment on a case-by-case basis.
‘Even though there is a limited role for opioids, there still is a role, but it requires accountable prescribing and continued monitoring,’ Dr Ackermann told newsGP.
Dr Ackermann is keen to emphasise, however, that the prescription of opioids is a ‘last resort’ treatment option that should only be considered once all other avenues have been exhausted.
‘The first step is a proper and comprehensive evaluation [of the patient],’ Dr Ackermann said. ‘Then you go through non-drug managements of chronic pain, then the non-opioid managements and, finally, if there is a population that are left who are in significant pain that produces significant disability, a trial of opioids can be undertaken.
‘When you undergo that trial of opioids, that’s exactly what it is, a trial to see if that patient is responsive to opioid therapy.
‘If the patient is not responsive to opioid therapy, then you’re obliged to take them off it.’
In the case of patients who do respond well to the treatment, it is important to maintain a long-term relationship with a medical professional so their opioid use can be regularly monitored – something for which Dr Ackermann feels GPs are extremely well-placed.
‘I think general practice is the place for these patients, and GPs generally manage this quite well,’ he said.
Dr Hester Wilson, GP and Chair of the RACGP Addiction Medicine network, agrees that opioids can’t be entirely ruled out as an option for chronic non-cancer pain treatment. But she argues that the risks these drugs present mean they should never be used as an ongoing medication.
‘Many of our patients may stay on a steady dose of opioids for a long time,’ Dr Wilson told newsGP. ‘But what other things are going on for them – are they escalating the dose? Are they seeking it from other doctors? Are they hugely anxious? Are they using it to manage their emotional state?
‘All those things are a really important part of a comprehensive assessment. At the end of that, you may form the decision that this medication is appropriate for this person, these are the boundaries, this is how you’re going to follow up and make sure that they are aware of the risks and only use it occasionally.’
codeine codeine-upscheduling opioid-misuse
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