Use of opiates in persistent pain

1. Opioids are very good analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain.

2. A small proportion of people may obtain good pain relief with opioids in the long-term if the dose can be kept low and especially if their use is intermittent (however it is difficult to identify these people at the point of opioid initiation).

3. The risk of harm increases substantially at doses above an oral morphine equivalent of 120mg/day, but there is no increased benefit: tapering or stopping high dose opioids needs careful planning and collaboration.

4. If a patient has pain that remains severe despite opioid treatment it means they are not working and should be stopped, even if no other treatment is available.

5. Chronic pain is very complex and if patients have refractory and disabling symptoms, particularly if they are on high opioid doses, a very detailed assessment of the many emotional influences on their pain experience is essential.

Reference: Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opiate medicines for pain (British Pain Society, Faculty of Pain Medicine and Public Health England 2019)

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Key message from Faculty of Pain Medicine of RCoA regarding opioid management for chronic non-cancer pain.

1. Patients who do not achieve useful pain relief from opioids within 2-4 weeks are unlikely to gain benefit in the long term.

2. Patients who may benefit from opioids in the long term will demonstrate a favourable response within 2-4 weeks.

3. Short-term efficacy does not guarantee long-term efficacy.

4. Data regarding improvement in quality of life with long-term opioid use are inconclusive.

5. There is no good evidence of dose-response with opioids, beyond doses used in clinical trials, usually up to 120mg/day morphine equivalent. There is no evidence for efficacy of high dose opioids in long-term pain.