Opioid use in Acute and Chronic Pain
One in five people in NSW suffers from persistent pain (defined as pain experienced every day for three months or more).1
Patients with persistentpain may present for treatment of:
- acute pain from unrelated injury or illness,
- exacerbation of chronic pain, or
- ongoing management of chronic pain.
- Use regular dosing rather than 'as required'.
- Use maximal doses before moving to the next step.
- Assess response to medications after 2-3 weeks.
- If the patient does not respond, review and explore reasons for non-response
- Consider combination therapy or addition of adjuvant medications. Choice of agents will depend on the diagnosis as well as pharmacological properties.
- Injectable opioids are rarely necessary. They should be reserved for patients with acute pain.
- Use of injectable opioids in drug dependent patients who have an acute injury is not necessarily contraindicated, but requires careful consideration and supervision.
Ideally, assessment by a pain clinic or consultation with a pain physician should precede the prescription of oral opioids. The prescription of opioid injections is appropriate for management of acute injury or unrelated pain (eg trauma, myocardial infarction). However, it is inappropriate in patients presenting with an exacerbation of persistent pain. Repeated administration of opioids by injection increases the risk of dependence, infection and nerve damage. Use of opioids should be part of a planned treatment strategy, not the consequence of patient pressure. Patients should not be prescribed injectable medication for self-administration or administration by carers, except in very exceptional circumstances (eg terminal care).
DRUG SEEKING BEHAVIOUR should be suspected when a patient
- Seeks injectable rather than oral opioids, or steadily increasing dose
- Seeks repeated supply of opioids
- Insists on a specific medication and refuses alternatives
- Requests supplies of opioids in more than one form (eg oral and injectable)
- Requests opioids by name, particularly pethidine
- Gives a vague or evasive history or has atypical pain or non-anatomical distribution
- Has lack of accompanying signs (eg no haematuria in renal colic)
- Denies having a regular practitioner and cannot provide names of previous doctors
- Attends multiple practitioners (history of 'Doctor Shopping")
- Is non-compliant with suggested treatment
- In addition to requesting opioids, requests other 'fashionable' drugs (eg Rohypnol®)
None of these clues in isolation is completely reliable. Use professional judgement. A complete history and thorough examination are particularly important in such situations.
Ref : TAG NSW Health