Examining the role of prescription opioids for chronic non-cancer pain

Amanda Lyons

15/01/2018 3:25:06 PM

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.
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.’

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Dr Ng   16/01/2018 5:44:19 PM

Firstly, I hope that the following does not come across as overly critical because I'm not writing with that intent. I would also like to stress that I agree with everything written - there are individual cases where a good doctor works with a diligent patient through a step-wise approach to symptom relief and arrives at the frustrating point where a short course of opioids for chronic pain is the only remaining option.

However, in my opinion, this article is extremely poorly timed. The use of opioids for chronic pain is only topical because of the impending disaster on February 1st when people dependent on codeine are no longer going to have access to their drug of choice without a prescription. As usual, the problem will be added onto the workload of the cheapest solution in healthcare - the GP. I believe that this article has done little except make the impending challenge MORE difficult.

The fact is that February 1 is going to unleash waves of people dependent on codeine, and with little motivation to stop, into GP waiting rooms. These addictions did not result from a careful step-wise approach to pain management under the supervision of a regular GP - but simply because popping a pill was quicker and easier than chronic pain management strategies. The truth is that these people should NOT be taking opioids, including codeine, for chronic pain and this should be the unified message of the medical community as February approaches. Instead this article ignored this unpleasant truth to instead discuss those rare cases where opiates may be appropriate.

This real problem with this article is that it provides opioid dependent people with ammunition to use against their GP when seeking a codeine prescription. The foundation on which every good GP builds a stance against drug-seeking patients - who use arguments like "my doctor has always prescribed it" and "it's the only thing that works for me" - is the evidence that these medications are not shown to be an effective treatment for chronic pain. But, now the RACGP has armed these people with an exception. For SOME people it's OK.

And, every patient dependent on opioids is going to believe that they are the exception. Non-pharmacological treatments didn't work for them - because they didn't have the motivation to participate. Simple analgesia didn't relieve their pain (as well as opioids). So, obviously, they are the rare person who's only option is an opioid prescription.

This article should have focused on the fact that that opioids are a poor choice for chronic pain. Yes, it is true that sometimes they are trialed in individual patients without evidence for their effectiveness, by their long term GP, but, this should have been a one line addendum at the end of the article. Furthermore, the article should have stressed that opioids should only ever be prescribed by the SOLE doctor who has walked the analgesic ladder with that particular patient - not handed out to a new patient who promises that the ladder didn't work for them.

The RACGP should make it clear that any patient who turns up to a new GP after February 1 requesting a codeine prescription for their chronic pain will, QUITE RIGHTLY, be refused. Any patient taking codeine for chronic pain should find a regular GP to assist them through opioid withdrawal before their stockpile of codeine expires. Anyone trying to find a new doctor to supply them with codeine scripts after February 1 is going to be met with rejection. Furthermore, given the demand for this type of appointment, I suspect that patients seeking codeine will find it difficult to even obtain an appointment to argue their case. GPs simply do not wish to endure circular, and irresolvable, debates with patients who only want something that the doctor will not provide.

This is the reality that the RACGP should be discussing - the fact that GPs will bluntly, and quite rightly, refuse to provide codeine for chronic pain. We should not be advertising the rare cases where it is justifiable to experiment with a short course of opioids, to long-term patients, after everything else has failed.


Dr Lisa Meriah Fraser   17/01/2018 1:40:06 PM

Thank you Dr Ng, the timing of an article like this does influence GPs and patients' perceptions.
You raise some important points. Specifically, these patients need REGULAR GPs, and a detailed plan, understood and agreed to by both parties, on how they will proceed. I like the way you have simplified things by saying the NEW GP for a patient in this situation may refuse. Also, that detailed, evidence-informed persistent pain management algorithms and plans would be a good thing to be getting dominant airtime and publication. I would like to reframe the term rejection because part of our approach will be to work hard to engage these people. A patient who never returns will happen, but that is not the ideal scenario and we need to work on relationships with these people. If you don't have a relationship, you have zero chance of the outcome you want. Not saying giving them the medication and nothing else, but saying i can give it to you on these conditions, with a view to stopping in this time frame and i will help you all the way.

Dr Amy Stinson   6/04/2022 8:28:28 AM

Dr Ng - I hope never to be a patient of yours, and tend to think from your comment that your manner might require some careful reflection.