The GPs need to be aware that the evidence for use of opioids
in non-cancer pain long-term is weak.
Partly we've not assessed the benefit after 12 months, but also partly because there's
a different perspective of chronic pain and the role of opioids,
and there's two parts to this.
The first is the chronic pain condition itself becomes less opioid responsive, and that in
part reflects the degree of neural sensitisation.
The second is opioids are less effective long-term from long-term exposure, do you impart to
opioid-induced hyperalgesia where the pain system is sensitised from opioid exposure
seen as arthralgias and myalgias on opioid withdrawal,
and the second is you get less effectiveness of opioid tolerance.
So therefore the ability to reduce pain intensity in the chronic use of opioids is less,
and so a pain intensity reduction of 30% is often seen as the goal of trials,
rather than an acute pain at maybe 50 or 70% dose reduction without pain intensity reduction.
Therefore the use of opioids in non-cancer pain long-term needs to be based on a
multi-dimensional assessment looking at who's the person, what are the mechanisms,
and in particular, is the ongoing nociception or neuropathic part
to the mechanisms of their pain and what's the impact.
Then you can define a goal set with the patient and with yourself
to define what the benefits wouldbe of an opioid trial.
In addition you will be looking at what are the side effects and the potential risks of
an opioid trial in a medium and long term, which includes short-term side effects, but
also long-term risk of opioid exposure, potential risks of tolerance and addiction, but also
issues with sleep disorder breathing, potential hormonal suppression.
Over the medium to longer term we should always be looking at potential dose reduction, maximising
the functional benefit of the use of opioids and then leading to opioid dose reduction
for the long-term health of the patient.
Some benefits of non-pharmacological approach is patient engagement,
which leads to increased compliance.
It should be based on this multi-dimensional assessment and goal setting with the patient,
and that includes a range of physical activity programs, which include simple walking, stretching,
hydrotherapy, leading to the more intensive approaches of aerobic exercise.
We prefer active management rather than passive approaches such as
massage or dry needling for example.
The second aspect is of the psychological approaches. So there's a range of
psychological approaches that look at appropriate assessment and then
stress reduction strategies, relaxation, pacing techniques and, in selected individuals, cognitive
behaviour approaches, which includes restructuring, may include mindfulness, it may include hypnosis,
which looks at activating the neuronal networks that are associated in pain modulation, and
may actually lead to pain reduction as well as less impact of the pain.
There are a number of non-opioid pharmacological strategies that are also utilised as part
of that multi-dimensional approach, and they include the antidepressant medications with
noradrenaline or the tricyclic group, which reduce pain sensitivity. There's a
typical antiepileptics, which are primarily the gabapentinoids and potentially valproate.