Opioids in the Treatment of Chronic Pain

Opioid therapy is the mainstay approach when treating chronic pain cases as it’s effective in relieving many types of pain. For millennia, opioids have been regarded the most effective medication for pain management – however, their use in advanced medical illnesses besides cancer continues to be a controversial topic amongst medical professionals and organisations.

Concerns related to the side effects, long-term efficacy, functional outcomes, and the potential for drug abuse and addiction have evolved over decades – in some cases these concerns have influenced a restrictive perspective on the use of opioids, while in others they have led to a greater willingness to endorse the treatment.

Opioids act by attaching to and activating opioid receptor proteins, these are found on nerve cells in the brain, spinal cord, gastrointestinal tract, and other organs in the body. When these drugs attach to their receptors, they inhibit the transmission of pain signals.

There are a range of drugs used for opioid therapy, including:

• Hydrocodone
• Diamorphine
• Morphine
• Codeine

There is no definitive answer as to how long it takes for opioids to work and how long they remain in the system. Diamorphine, is a particularly well known fast-acting drug which provides relief for approximately two hours while morphine typically takes longer to take effect but provides longer relief.

Opioids can be very addictive and in as little as two weeks of daily consumption can create a physical dependence. This is where the person taking the drug relies on it to prevent withdrawal symptoms. There is a common misconception that opioid withdrawal symptoms are merely the original pain resurfacing, this can influence the sufferer to believe they need a higher dose to achieve a similar level of pain relief. This is why opioid treatment needs to be carefully managed by the prescribing practitioner and a full case history is required to assess whether this is the best treatment to prescribe.

Case Study

A case study that supports the current controversy surrounding opioid use is the tragic case of Mrs X, who was under the care of her General Practitioner for 16 years, who it is argued, breached his duty of care by prescribing large amounts of opioid analgesia without attempting to identify the underlying cause of the patient’s persistent pain. Mrs X initially experienced chronic back pain that radiated to her neck, shoulders, legs, chin and kidneys and her over prescribed opioid medication over the years only worsened her condition. The very sad result of this lack of patient management by the treating physician resulted in Mrs X taking her own life. This is an extreme case of over-prescribing opioid medication when a multi-modal approach should have been adopted as well as diagnostics to understand the source of her pain.

Why is the use of opioids a controversial topic?

Despite the support of pain specialists and the highly ethical and medically justified use of opioid therapy to treat chronic pain, there is concern that the pendulum has swung from under-treatment to over-treatment. This controversy is enhanced by the increased prevalence of prescription opioid abuse.

Acknowledging the severity and prevalence of opioid misuse, it’s imperative to follow practice guidelines when prescribing opioids, except when another course of action is demonstrably justified. These guidelines emphasise the need to initiate, structure and monitor therapy in a manner that both optimises the positive outcomes of opioid therapy and minimise the risks associated with abuse, addiction and diversion.

Physicians should ensure their patients’ pain is properly assessed and managed both at the outset and ongoing at regular intervals. Opioids can offer a good outcome, however the obligation to provide pain relief must be balanced with an equally important responsibility not to expose patients, especially vulnerable patients, to the risk of addiction and to ensure at all costs there is no opportunity for the creation of drug diversion, trafficking, and the addiction of others.

Read the governments article on ‘Reducing the Risks of Opioid-Related Deaths’ for more information.

Watch our expert, Dr Christopher A. Jenner’s video to learn more about opioids: