Professor Lesley Colvin and Professor Blair Smith outline key learning points on the use of opioids from the updated SIGN guideline on the management of chronic pain
Read this article to learn more about:
- updated recommendations on opioid use for chronic pain
- early review of patients after starting opioids
- non-pharmacological management strategies for chronic pain.
Chronic pain, that is pain lasting for longer than 12 weeks, is a major clinical challenge, with an increasing incidence in an ageing population, often alongside other co-morbidities.1 In the UK, a recent systematic review and meta-analysis of population studies found a prevalence of 43%.2 Around 14% of people, particularly women and older adults, report ‘significant chronic pain’, which requires treatment and support.3 Chronic pain has a negative effect on individuals, their families, and their carers, creating a large societal burden, and a coordinated approach is needed to address this.
Modern pain management uses a biopsychosocial approach, in which careful assessment of all aspects is required to formulate a multidisciplinary management plan. It is unlikely that analgesics alone will provide effective management, optimise successful outcomes, or minimise long-term harms. Despite this, the use of opioids for chronic, non-malignant pain has increased dramatically over the last two decades. In the US, where opioid prescribing increased steadily from 2006, peaking in 2012 at a rate of 81.3 prescriptions per 100 patients,4 it has been termed an ‘epidemic’ by the US Surgeon General.5 Mortality associated with unprescribed and prescribed opioids is a major problem in the US, where deaths from prescription opioids have increased by almost 400% since 1999.6–8 The prescribing rates of strong opioids more than doubled in Scotland between 2002 and 2012, although there was marked regional variation and an association with deprivation, similar to that seen in England. Not only has there been an increase in the number of prescriptions for opioids, but also an increase in the morphine equivalent doses prescribed.9–11
The reasons for these increases are complex and include:
- the introduction of pain as the fifth vital sign by the American Pain Society12
- new opioids and/or formulations becoming available
- changes in societal expectations
- historical recommendations of specialist medical societies
- the concept that opioids used for pain relief would not result in addiction, and the introduction of the term ‘pseudo-addiction’, despite little in the way of scientific evidence.13,14
1. Know what the evidence says about opioid use
It is important to consider how the evidence about chronic pain management and particularly the use of opioids has evolved.
When the Scottish Intercollegiate Guidelines Network (SIGN) published its first guideline on the management of chronic pain (SIGN 136)1 in 2013, the evidence for opioid use for chronic pain was assessed.15 This included evidence for efficacy compared with placebo, as well as information about adverse events regarding strong opioids, plus tramadol, codeine, and compound preparations. Parenteral and neuraxial routes of administration were excluded.1
Previously, one of the key recommendations was that strong opioids should be considered for chronic lower back pain or osteoarthritis, and only continued if there was ongoing pain relief. Regular review was recommended.1,15 This recommendation is no longer current; it was also noted that there were deficiencies in the evidence, with no good quality randomised controlled trials (RCTs) beyond 6 months of use, as well as a likelihood of overestimation of treatment effect because of the type of analysis used.1
In August 2019, the opioids section of SIGN 136 was updated to reflect significant changes in the evidence base, with an alteration in the balance of risks and benefits (Figure 1).1 A wide body of literature explores the harms associated with long-term opioid use, which include addiction and misuse, tolerance, endocrine dysfunction, increased risk of cardiovascular events, and being involved in a road traffic incident.16,17 Despite this, it was not until 2018 that the first longer-term RCT was published, comparing opioid with non-opioid analgesics in the management of chronic back pain, or hip or knee osteoarthritis pain.18 In this study, patients who were on opioids for 12 months were found to have worse pain, with no improvement in function, compared with those on non-opioid analgesics (see Figure 1).18
2. Prescribe opioids in line with restrictions
In light of the accumulated change in evidence, the 2019 version of SIGN 136 includes new recommendations around opioid use, which place more restrictions around indications and duration of use (see Box 1).
Box 1: Key recommendations on opioid use from SIGN 1361
- Opioids should be considered for short- to medium-term treatment of carefully selected patients with chronic non-malignant pain, for whom other therapies have been insufficient, and the benefits may outweigh the risks of serious harms such as addiction, overdose and death
- At initiation of treatment, ensure there is agreement between prescriber and patient about expected outcomes (see Figure 2 and Annex 4 of SIGN 136). If these are not attained, then there should be a plan agreed in advance to reduce and stop opioids
- All patients on opioids should be assessed early after initiation, with planned reviews thereafter. These should be reviewed annually, at a minimum, but more frequently if required. The aim is to achieve the minimum effective dose and avoid harm. Treatment goals may include improvements in pain relief, function and quality of life. Consideration should be given to a gradual early reduction to the lowest effective dose or complete cessation
- Currently available screening tools should not be relied upon to obtain an accurate prediction of patients at risk of developing problem opioid use, but may have some utility as part of careful assessment either before or during treatment
- Signs of abuse, addiction, and/or other harms should be sought at reassessment of patients using strong opioids
- All patients receiving opioid doses of >50 mg/day morphine equivalent should be reviewed regularly (at least annually) to detect emerging harms and consider ongoing effectiveness. Pain specialist advice or review should be sought at doses >90 mg/day morphine equivalent.
Scottish Intercollegiate Guidelines Network. SIGN. Management of chronic pain. SIGN 136. Edinburgh: SIGN, 2013, updated 2019. Available at: www.sign.ac.uk/assets/sign136_2019.pdf
Reproduced with permission.
3. Consider non-pharmacological management strategies
The updated SIGN 136 guideline recommendations echo a 2018 position statement by the International Association for the Study of Pain (IASP),19 which reiterates the importance of continued access to opioids for acute pain management, but advises caution when these are used for chronic pain. Similarly to the SIGN 136 guideline update, short- to medium-term use of low-dose opioids in selected, well-monitored patients is presented as an option, but other strategies combining physical and behavioural therapies are preferred, with stronger evidence of efficacy and a low risk of harm.19,20
4. Assess suitability and monitor carefully when prescribing strong opioids
The SIGN pathway for using strong opioids in patients with chronic pain has also been updated to reflect the new recommendations, and provides practical guidance about how and when to start strong opioids. The pathway (summarised in Figure 2) is broken down into three sections, which focus on:1
- assessing suitability for strong opioid use
- starting a strong opioid
- monitoring opioid trial.
Strong opioids should not be commenced until there has been a careful assessment of the patient and a discussion about when to stop treatment. Treatment should be titrated to the lowest effective dose, balanced against side-effects, and reviewed regularly.
5. Use non-pharmacological approaches and support self-management
Although the other sections of SIGN 136 have not been updated, the importance of an integrated multidisciplinary approach remains central to the management of people with chronic pain. This approach should be based on a biopsychosocial assessment to formulate a management plan, using pharmacological management when appropriate, alongside physical and psychological therapies, and supported self-management. In general, avoid using strong opioids as the main treatment approach.
On a positive note, more recent analyses have indicated a stabilisation or even decrease in opioid prescribing rates in Scotland (scotland.shinyapps.io/nhs-prescribing-nti/)21 and in the US, where prescription behaviour surveillance systems have been implemented.22
The focus, however, should not just be on a reduction in prescribed opioids with no alternative strategies. Health and social care services need to meet the requirements of people with chronic pain, providing easy access to evidence-based social prescribing and non-pharmacological management. Alongside this, continued research into novel analgesics that reduce pain with minimal adverse effects from long-term use and careful evaluation of non-pharmacological interventions will help to reduce the overall burden of chronic pain.
In conclusion, opioid use for chronic pain is now recommended under much more restricted conditions than previously. This is because of an increase in the evidence around potential significant harms, and emerging evidence about limited long-term efficacy, although further research is needed in this area. Importantly, opioids should not be used as a single strategy in chronic pain management, but as part of a wider plan, with careful assessment and review throughout the period of use. Non-pharmacological approaches, including strategies to support increases in physical activity, should form a key component of chronic pain management, to improve function and quality of life.
Professor Lesley Colvin
Professor of Pain Medicine and Consultant in Anaesthesia and Pain Medicine, University of Dundee; Honorary Consultant, NHS Tayside
Member of the guideline development group for SIGN 136
Professor Blair Smith
Professor of Population Health Sciences and Consultant in Pain Medicine, University of Dundee; Honorary Consultant, NHS Tayside
Member of the guideline development group for SIGN 136
Implementation actions for STPs and ICSs
The following implementation actions are designed to support STPs and ICSs with the challenges involved with implementing new guidance at a system level. Our aim is to help you consider how to deliver improvements to healthcare within the available resources.
- Inform all relevant prescribers of the latest evidence on the use of opioids and the lack of evidence of benefit in chronic non-malignant pain
- Update all formulary guidance to reflect this latest evidence and include information about how and when to initiate strong opioids and when to review the need for these
- Enact targeted structured medication reviews by pharmacists for patients currently prescribed these medications, to explore possible reductions in dosages
- Ensure non-pharmacological interventions are available on referral to avoid dependence on medication
- Make available advice and guidance for patients on the management of pain through local pain clinics.
STP=sustainability and transformation partnership; ICS=integrated care system
Implementation actions for clinical pharmacists in general practice
written by Gupinder Syan, Training and Clinical Outcomes Manager, Soar Beyond Ltd
- Identify patients in your practice with chronic pain who are taking long-term opioids (>12 weeks’ duration) and check to see if there is a review management plan in place for each. Consider further stratification e.g. those on strong doses of opioids (>50 mg/day morphine equivalent), those with other LTCs, or where there are QOF targets to manage
- Establish with the practice who will manage these patients and set accountabilities, e.g. named GPs to manage more complex patients and GP pharmacist to manage those within their level of competence
- Prepare before seeing patients to ensure that you are competent to manage this patient cohort. For example:
- familiarise yourself with SIGN guideline 136
- shadow/observe other HCPs to help improve your counselling skills with patients in supporting them to reduce opioid use down to the minimum effective dose or wean down to stop
- know referral pathways to pain teams (for patients on doses >90 mg/day morphine equivalent) and other HCPs (e.g. physiotherapist or psychological support) to ensure there is a multi-disciplinary approach to management
- empower other clinicians to support appropriate opioid use by sharing your knowledge with them and encouraging them to set realistic expectations about treatment duration when opioids are started
- Deliver clinics and ensure there is an agreed management plan in place with the patients you see that includes a review date for reducing or weaning to stop opioid use, or considering other non-opioid measures if appropriate. Refer more complex patients to relevant services. Code all interventions made to enable you to capture your outcomes.
- Evaluate your outcomes—examples include:
- number of patients seen for an opioid medication review, and number of management plans agreed
- number of patients whose opioid doses have been reduced or stopped, or changed to alternative pain relief treatment.
LTS=long-term conditions; QOF=quality and outcomes framework; HCP=healthcare practitioners
- Scottish Intercollegiate Guidelines Network. Management of chronic pain. SIGN 136. Edinburgh: SIGN, 2013, updated 2019. Available at: www.sign.ac.uk/assets/sign136_2019.pdf
- Fayaz A, Croft P, Langford R et al. Prevalence of chronic pain in the UK: a systematic review and meta-analysis of population studies. BMJ Open 2016; 6: e010364.
- Smith B, Elliott A, Chambers W et al. The impact of chronic pain in the community. Fam Pract 2001; 18 (3): 292–299.
- Centers for Disease Control and Prevention. Prescribing practices. www.cdc.gov/drugoverdose/data/prescribing/prescribing-practices.html (accessed 4 March 2020).
- US Department of Health and Human Services, Office of the Surgeon General. Facing addiction in America—the Surgeon General’s spotlight on opioids. Washington DC: DHHS, 2018. Available at: addiction.surgeongeneral.gov/sites/default/files/Spotlight-on-Opioids_09192018.pdf
- National Institute on Drug Abuse. Overdose death rates. www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates (accessed 4 March 2020).
- Benzon H, Anderson T. Themed issue on the opioid epidemic: what have we learned? Where do we go from here? Anes Analg 2017; 125 (5): 1435–1437.
- Huang X, Keyes K, Li G. Increasing prescription opioid and heroin overdose mortality in the United States, 1999-2014: an age-period-cohort analysis. Am J Public Health 2018; 108 (1): 131–136.
- Torrance N, Mansoor R, Wang H et al. Association of opioid prescribing practices with chronic pain and benzodiazepine co-prescription: a primary care data linkage study. Br J Anaesth 2018; 120 (6): 1345–1355.
- Mordecai L, Reynolds C, Donaldson L, de C Williams A. Patterns of regional variation of opioid prescribing in primary care in England: a retrospective observational study. Br J Gen Pract 2018; 68 (668): e225–e233.
- Curtis H, Croker R, Walker A et al. Opioid prescribing trends and geographical variation in England, 1998-2018: a retrospective database study. Lancet Psychiatry 2019; 6 (2): 140–150.
- Campbell J. APS 1995 presidential address. J Pain 1996; 5 (1): 85–88.
- Greene M, Chambers R. Pseudoaddiction: fact or fiction? An investigation of the medical literature. Curr Addict Rep 2015; 2: 310–317.
- Portenoy R, Foley K. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. 1986 May;25(2):171-86. PubMed PMID: 2873550.
- Smith B, Hardman J, Stein A, Colvin L; on behalf of the SIGN Chronic Pain Guideline Development Group. Managing chronic pain in the non-specialist setting: a new SIGN guideline. Br J Gen Pract 2014; 64 (624): e462–e464.
- Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA 2016; 315 (15): 1624–1645.
- Chou R, Turner J, Devine E et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015; 162 (4): 276–286.
- Krebs E, Gravely A, Nugent S et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: the SPACE randomized clinical trial. JAMA 2018; 319 (9): 872–882.
- International Association for the Study of Pain. IASP statement on opioids. www.iasp-pain.org/Advocacy/OpioidPositionStatement (accessed 20 February 2020).
- Geneen L, Moore R, Clarke C et al. Physical activity and exercise for chronic pain in adults: an overview of Cochrane Reviews. Cochrane Database Syst Rev 2017; (4): CD011279.
- Information Services Division, NHS National Services Scotland. NHS Board national therapeutic indicators: analgesics (opioid DDDs)—Dec 2015–Sep 2019. scotland.shinyapps.io/nhs-prescribing-nti/ (accessed 21 February 2020).
- Strickler G, Kreiner P, Halpin J et al. Opioid prescribing behaviors—prescription behavior surveillance system, 11 states, 2010–2016. MMWR Surveill Summ 2020; 69 (1): 1–14.