Type of pain and timing of therapy

There is evidence for effectiveness of opioid therapy for acute pain management. Similarly opioids have a circumscribed role in the management of cancer pain, particularly towards the end of life. In general, poorly defined pain of uncertain aetiology with no abnormal findings on imaging investigations would be less likely to respond to opioid therapy. Clearly defined pain associated with identifiable organic disease may respond to opioids but even well-defined syndromes including major joint osteoarthritis demonstrate a disappointing response to opioids when used over a long period of time. Paroxysmal pain where the patient experiences episodes of pain with rapid onset and of short lived duration is difficult to manage with opioid drugs or other medications.

The decision to prescribe opioids for long-term pain should be carefully considered. In particular it is important to consider:

• the importance of shared decision making in relation to opioid treatment: this should include the patient, the prescriber, the patient’s GP (if not the prescriber) and other key individuals involved in the patient’s care
• when to start opioids in relation to other therapies: non-opioid interventions (pharmacological or non-pharmacological) should be considered before opioid therapy where there is good scientific rationale for these interventions. It will usually be appropriate to continue effective or partially effective interventions in parallel with opioid therapy
• the specific problems of using opioids to support discharge from hospital. Opioids play an important role in acute pain management. Many patients in hospital with physical trauma or following surgery will be expected to have some pain for a short period following discharge. It may be appropriate to offer the patient a supply of opioid medicine sufficient for a few days after which opioids are unlikely to be needed. The patient must be given clear instructions regarding how to taper the dose of drug as natural recovery takes place and the treatment plan including the estimated time of cessation of opioid therapy should be communicated to the patient’s GP.