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

The letter by Alderman and colleagues is a timely reminder of the continued importance of post-marketing surveillance, especially for medications with frequently encountered and well characterised harms. As outlined, such surveillance must include all medications, whether or not they are subsidised or sold over the counter, in order to account for drug–host and drug–drug interactions.

Pain is prevalent in the elderly and when residents in residential aged care facilities (RACFs) are asked to rate pain themselves, up to two-thirds of them confirm its presence.1 Pain is a symptom encountered frequently in this clinical care, is mostly multifactorial and requires a response that decreases its intensity and hence reduces suffering.

It is unlikely that many residents of RACFs are ever referred for assessments by chronic pain services in Australia. The responsibility for management of chronic pain in the frail elderly falls almost entirely on general practitioners, nurses, care workers and pharmacists. Reducing pain in RACFs requires a whole-of-systems response that promotes clinician capacity building (such as audit and feedback, education, training and coaching); non-pharmacological and pharmacological interventions tailored to each resident’s unique pain needs, including the World Health Organization analgesic ladder step 3 opioids, such as morphine or oxycodone, for some carefully selected residents;2 and ongoing pharmacovigilance studies.

The real-world mapping of prescribing in groups at particular risk of adverse events needs to be more widespread in the health system.3 This is even more important when the groups being studied were almost certainly excluded systematically from the phase 2 and 3 studies that formed the basis of current registered indications.4 Greater investment in high quality pharmacovigilance is an investment in reducing harm and better targeting of therapies — the essence of personalised medicine.

Current evidence for the management of chronic non-malignant pain is being systematically synthesised as it evolves. Bennett and colleagues point to resources that help to inform the excellent practice support offered by the NPS MedicineWise program.5 By focusing on managing pain, it is hoped that needless suffering can be reduced safely across the whole community.