Using opioids in general practice for chronic non-cancer pain: an overview of current evidence

Currow and colleagues1 discuss a complex and controversial therapeutic area — the use of opioids in chronic non-cancer pain (CNCP) — where it is acknowledged that there is a paucity of evidence demonstrating opioid effectiveness in long term management. The generally poor management of CNCP, including over-reliance on opioid use, may be attributed to lack of knowledge about the complex nature of CNCP and the role of non-drug options for treatment.

We are disappointed that, although it referred to the NPS MedicineWise resources,2 the article did not mention recent freely available Australian guidance documents for the use of opioids in CNCP from the Faculty of Pain Medicine of the Australian and New Zealand College of Anaesthetists3 and the New South Wales Therapeutic Advisory Group (TAG).4 A web-based repository of pain management resources, from the NSW Agency for Clinical Innovation, is also useful.5 The NSW TAG document was developed by a multidisciplinary group to provide succinct, user-friendly, best-practice guidance addressing the clinical, legal and ethical challenges faced by busy general practitioners.

These documents provide an Australian context for the use of medicines in CNCP, which is different from their use in managing acute pain or pain in palliative care settings. They recognise the multidimensional nature of CNCP, which means that it is difficult to refer to “well defined” pain, as do Currow and colleagues. The documents support a multidisciplinary approach to patients with CNCP that emphasises non-pharmacological over pharmacological treatment and promotes self-management. The outcome of drug therapy in CNCP is unpredictable, as this treatment is directed to a patient experiencing pain rather than a biomedical target. Therefore, when pharmacological treatment with opioids is considered, it is done only as a trial in conjunction with other approaches, limited in duration and dosage and with regular monitoring. Such a trial must include an assessment of potential misuse. Contrary to the statement of Currow and colleagues that tamper-resistant opioids offer “the highest level of prevention of opioid misuse”, we believe that the main way to prevent misuse is to be cautious in prescribing.