Volume 195 - Issue 5
Should opioids be used for chronic non-cancer pain?
Author: Mark S Awerbuch
Med J Aust 2011; 195 (5): 264-265. || doi: 10.5694/mja11.10624
Published online: 5 September 2011
Published online: 5 September 2011
To the Editor: A report in the Weekend Australian earlier this year described an increase in oxycodone-associated deaths, in parallel with an increase in prescriptions for the drug, sometimes known as “hillbilly heroin”.1 These increases are likely to reflect a change in doctors’ prescribing behaviour.
Strong opioids were traditionally prescribed for cancer pain, often in the terminally ill, but since the 1980s they have been increasingly used for treating chronic non-cancer pain, despite an absence of new evidence of effectiveness or of whether opioids provide net benefit or harm to patients in this setting.2 Cancer patients are likely to die from their illness before the opioids have a chance to injure them, but patients with chronic non-cancer pain are not, and this is where oxycodone-associated deaths are more likely to occur.
A contemporary view is that chronic non-cancer pain should be regarded as “a disease entity”,3 but equating a symptom with disease means that the patient becomes the sole arbiter of whether he or she is ill. The prescribing doctor has no means by which to objectively determine treatment outcomes.
The notion of chronic non-cancer pain as a disease entity is based on neuropathological changes described as “central sensitisation”, which may result from nerve damage or from persistent peripheral nociceptive input.3 The concept is not intellectually challenging where there is objective evidence of either nerve damage or injury to somatic or visceral structures. Now, however, when medically inexplicable pain follows injury that may be so subtle as to be unassociated with any discernible abnormality, central sensitisation is invoked as the explanation du jour, without a critical assessment based on anatomical and physiological principles. Prescribing opioids in this setting may have inadvertently contributed to the reported increase in oxycodone-associated deaths.
Guidelines exist for prescribing oral controlled-release opioid analgesics for chronic non-cancer pain.4-6 They advocate a signed patient–doctor agreement covering, among other things: the necessity for a single prescriber; a recommendation for all drug dispensing to be from the same pharmacy; no replacement for lost, stolen or destroyed prescriptions; and a requirement for consent for random urine and blood screens.
However, these are just guidelines, not mandated, and there are no Australian data on compliance with them. Based on international data,7 the guidelines are likely to be more honoured in the breach than the observance.
I advocate that a signed patient–doctor agreement should be mandatory in Australia before the prescription and dispensing of opioids for chronic non-cancer pain. This should be sighted by Pharmaceutical Benefits Scheme authorities before such dispensing is authorised, and a copy should be held by the dispensing pharmacy. A review of prescription guidelines for opioid analgesics in chronic non-cancer pain might reduce the epidemic of prescription drug misuse4 and mortality.
Competing interests
No relevant disclosures.
References
- Cresswell A. Alarm over death links with opioid painkillers. Weekend Australian (Sydney) 2011; 14-15 May. http://www.theaustralian.com.au/national-affairs/alarm-over-death-links-with-opioid-painkillers/story-fn59niix-1226055613352 (accessed Jul 2011).
- Sullivan MD, Edlund MJ, Fan MY, et al. Trends in use of opioids for non-cancer pain conditions 2000–2005 in commercial and Medicaid insurance plans: the TROUP study. Pain 2008; 138: 440-449. 0_i1140167
- Siddall PJ, Cousins MJ. Persistent pain as a disease entity: implications for clinical management. Anesth Analg 2004; 99: 510-520. 0_i1140169
- Trescot AM, Helm S, Hansen H, et al. Opioids in the management of chronic non-cancer pain: an update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines. Pain Physician 2008; 11 (2 Suppl): S5-S62. 0_i1140171
- Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10: 113-130. 0_pgfId-2421692
- Graziotti PJ, Goucke CR. The use of oral opioids in patients with chronic non-cancer pain: management strategies. Med J Aust 1997; 167: 30-34. 0_i1140174
- Victor TW, Alvarez NA, Gould E. Opioid prescribing practices in chronic pain management: guidelines do not sufficiently influence clinical practice. J Pain 2009; 10: 1051-1057. 0_i1140178