Blair H. Smith
Consultant in Pain Medicine, and National Lead Clinician for Chronic Pain for the Scottish Government
Chronic pain conditions account for one in five GP appointments and can be undertreated. Opioids can be part of an effective management plan for those with long-term pain.
Opium has been used in the treatment of pain for thousands of years. Derived from the opium poppy, it is the substance from which prescription pain relievers – a class of drugs known as opioids, such as morphine and codeine – are made.
“A number of opioids exist, which are all related but work in slightly different ways in different parts of the nervous system,” says Blair H. Smith, a Consultant in Pain Medicine at NHS Tayside and National Lead Clinician for Chronic Pain for the Scottish Government.
Doctor and patient must share goals
When it comes to treating chronic pain with opioids, he advocates ‘good prescribing’ – an undertaking that requires patient and doctor to set shared, realistic goals about achievable levels of pain reduction.
The main role of opioids is to allow self-management and improve the patient’s function and quality of life, says Smith, so that patients have the opportunity to develop alternative pain management strategies such as those afforded by increased levels of fitness.
Aim to improve the patient’s function and quality of life, to the point where they have the opportunity to develop alternative pain management strategies, such as increased levels of fitness.
“Being active is important with chronic pain because it helps the body to produce more endorphins, which alleviate pain and increase well-being. Carrying less weight also relieves strain on the joints.”
At that point, says Smith, “It’s often possible to cut back on the opioids, and this should be the aim.”
Another aspect of good prescribing involves taking a holistic view of the patient’s condition and addressing some of the adverse effects associated with opioids such as nausea, for which anti-nausea medication might be given. Other adverse effects, though, are harder to deal with and include fatigue, reduced immune function and hormone changes.
Another adverse effect is addiction. Though “the known risk of addiction can be minimised with good prescribing and care in looking out for the signs, or avoiding their use in people whose past history includes substance misuse,” he says. Meanwhile a frequent review of medication is required so that patients “don’t get stuck forever on a certain dose”.
Long-term pain impacts lives
Smith recalls a patient who described his chronic pain as, “an unwelcome guest who lives with you and who must be consulted before you do anything.”
While that ‘unwelcome guest’ might prove mildly inconvenient in some cases, in others it is debilitating; 17 per cent of patients with chronic neuropathic/nerve-related pain rate their suffering as being ‘worse than death.’
In those circumstances, the long-term use of opioids might be a necessary fact of life in order to ensure a certain quality of life. But these still must be used with caution, frequent review, attention to side effects, and a holistic approach to managing pain through other means as well.
“If longer-term users are living and functioning well with opioids and their dose isn’t going up and up, then that is what I would call successful treatment,” says Smith.
Fear of addiction can lead to under-treatment
A reticence in prescribing can sometimes occur though, when those with chronic pain are undertreated, and their desire for greater pain relief is misinterpreted as symptoms of addiction.
Desire for greater pain relief is misinterpreted as symptoms of addiction.
“There are times where a stronger dose would be more effective for the patient but medical professionals incorrectly suspect inappropriate drug-seeking behaviour,” says Smith, explaining that the risk of addiction is minimised by providing education about opioids so that patients and doctors can work together on the look-out for potential signs.
“With careful prescribing, the risk of addiction is probably low,” he says.
