Eileen Mann, BSc (Hons), RN, SCM, DPSN, PGCHE.
Nurse Consultant Pain Management, Institute of Health and Community Studies, Bournemouth University and Poole Hospital NHS TrustThis paper will explore the role of strong opioids for chronic non-malignant pain and the issues that arise in both acute and community settings. It will review some of the controversies and the paradoxes, explore the evidence that supports their use, as well as some of the undeniable pitfalls associated with strong opioid analgesia for patients, nurses and doctors, particularly within the primary care setting.
Opioids are undeniably our most powerful analgesics, but equally undeniably politics, prejudice and our continuing ignorance impedes optimum prescribing (McQuay, 1999). Over 100 years ago opium poppies were grown on the Fens in Cambridgeshire to provide opium for working men, but the brewing lobby, concerned that opium would erode their market share, argued on thin evidence that alcohol was less dangerous (McQuay, 1999). Restrictions were eventually put on opioids worldwide and have undoubtedly ensured that their beneficial use has not been optimised.
Exploring the issues that support or dismiss the use of opioids for chronic non-malignant pain is not easy. As previously stated, we have good data now that indicates the efficacy of opioids in acute and cancer pain without relevant tolerance development, with easy-to-manage physical dependence and an insignificant risk of drug abuse (Schug et al, 2002).
If we accept that there is now good evidence that subjective pain perception can be reduced with opioids for certain types of chronic pain, what else must be achieved? It is generally recognised that just reducing pain, although a very real and important goal for patients, should not be the single aim of prescribing clinicians. Just reducing pain intensity can have a negative impact on patients if it is achieved at the cost of a poorer quality of life. Many patients, even when pain relief has been reported as significant, have dropped out of studies and discontinued opioid use for a variety of reasons related to side-effects or just a reluctance to continue the therapy (Kalso, 2002). Any pain relief achieved needs to be accompanied by an increase in functioning and activity, improved lifestyle and a decrease in perceived stress. Other factors that are usually studied and deemed significant include sleep pattern, fatigue, mood and side-effects. The risk of these drugs being diverted to those who use drugs for non-medical reasons must also be considered.
Opioids also have the potential to induce tolerance to their beneficial effect, cause physical dependence and addiction. Tolerance in this instance refers to the state of reduced responsiveness to the effects of a drug following previous administration. Similar to their administration for an acute pain, tolerance following chronic opioid use appears to be uncommon, with many patients stabilised on a long-term dose (Zenz et al, 1992).
To improve and rationalise the use of strong opioids in primary care, the use of agreements or contracts with patients can offer a solution. These have been developed to provide a broad support structure of fully informed health professionals who monitor patients closely. The emphasis is on the importance of pain relief but is coupled to enhanced function via the active continuation of other therapy (Burchman and Pagel, 1995).
We still have a long way to go to get it right but the picture on opioids is certainly looking clearer and help is out there to assist patients, clinicians and institutions to approach the use of opioids in a logical and evidence-based fashion. Although opioids should be only one part of a strategy to improve pain control, we need to ensure that those patients who may well derive benefit from their use are identified and managed in the best possible way.
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