Quick steps through Opioid Management

Opioid Quicksteps Guide

This on-line tool outlines a balanced approach to safer opioid prescription as part of multimodal pain management. There is strong evidence that risk increases substantially above 60 mg/day oral morphine equivalent daily dose (oMEDD). For this reason, in this resource, 60 mg oMEDD is chosen as a threshold for increased risk and recommendations are built around this level although recognising the need to consider the specific risks of each individual. In general, in the chronic non-cancer pain setting, opioids (including codeine) should be avoided other than in exceptional circumstances. These include the presence of severe opioid responsive pain where other management options have failed or are inappropriate. Opioids should not be prescribed above 60mg oMEDD without pain medicine specialist endorsement.

In this tool, you will find recommendations and resources for the management of people with chronic non-cancer pain at each stage of prescribing – whether you are considering, starting, continuing at or below 60 mg oMEDD, continuing above 60 mg oMEDD or reducing opioids. Simply click on the tabs below to find the recommendations.

  1. Broad pain assessment with development of a pain management plan.
  2. Assess for the presence of red flags and investigate and treat as required.
  3. Assess for the presence of yellow flags and treat or refer as appropriate.
  4. Educate the person about the nature of pain, the lack of effectiveness of opioids in treating chronic pain and potential side effects and harm of opioids.
  5. Assist the person to develop pain self-management skills and strategies to maintain activity despite the presence of pain (e.g. activity pacing, reducing reliance on aids, managing unhelpful thoughts and non-drug calming techniques) with the use of available resources (ACI website, pain self-management books).
  6. Trial and ensure appropriate use of available treatments (e.g. pain self-management strategies, physiotherapy, exercise physiology, clinical psychology, first-line medications, etc.).
  7. If inadequate response, consider more intensive pain management skills training (e.g. on-line or group pain management program).
  8. Assess potential harm from opioid use (opioid risk tool) as well as other concomitant risks (e.g. use of central nervous system depressants).
  9. Consider obtaining input from a pain management or drug and alcohol (if past history indicates) service prior to prescribing. Always obtain advice from a specialist pain medicine physician or paediatrician before prescribing opioids to children and adolescents.

Question

Given the known lack of long term effectiveness of opioids at a population level and potential side effects, what is the rationale for starting this person on opioids?

Criteria
  1. Consider obtaining specialist pain medicine physician advice before starting opioids. Always obtain advice from a specialist pain medicine physician or paediatrician before prescribing opioids to children and adolescents.
  2. Ensure that opioids are not being accessed through another prescriber.
  3. Ensure the person is already using appropriate pain self-management strategies.
  4. Explain the low likelihood of effectiveness and high likelihood of adverse effects when using opioids for treating chronic non-cancer pain.
  5. Consider using a prescribing agreement including informed consent.
  6. Consider weaning or ceasing other drugs that increase risk, e.g. benzodiazepines.
  7. Start time-limited (2 month) and dose limited (up to 60 mg oMEDD (opioid calculator)*) opioid trial to determine effectiveness (both improved function and pain relief) and side effects.
  8. If trial is successful (reduction in PEG score by 30%), and there is ongoing need, continue with regular (< 3 monthly) monitoring and review by prescriber, and ongoing use of pain self-management strategies.
  9. If trial is successful but opioids are no longer needed, wean and cease.
  10. If trial is unsuccessful, (reduction in PEG score by less than 30%) wean and cease.
  11. If trial is unsuccessful or difficulties with opioid reduction, seek guidance from a pain management service.
  1. If successful trial or already using opioids (<60 mg oMEDD), regular (minimum 3 monthly) monitoring and review by prescriber for effectiveness, side effects, misuse or diversion.
  2. Encourage ongoing use of pain self-management strategies.
  3. Follow medico-legal guidelines and drug and alcohol safe prescribing practices.
  4. If able to manage pain with lower doses or any concerns regarding side effects, reduce opioids.
  5. Do not prescribe >60 mg oMEDD* without endorsement of pain management service.
  6. Consider opioid substitution therapy.
  7. If use is expected to continue for >12 months, the patient's pain management must be reviewed through consultation with the patient by another medical practitioner or specialist pain medicine physician

Safety Message

*30 mg oMEDD in older people (age >65 years) and 1.2 mg /kg/day for children and those <50kg with chronic medical illnesses

Question

Given the potential for harm, what is the rationale for maintaining this person on this dose of opioids?

Criterion
  1. Ensure patient awareness of low likelihood of long term effectiveness of opioids and known side effects and potential for serious harm, especially at doses above 60 mg oMEDD.
  2. Consider baseline investigations to detect harm (e.g. hormones, bone density).
  3. Consider risk of overdose: naloxone prescription and or suitability for opioid substitution therapy.
  4. If possible, introduce an opioid weaning protocol.
  5. Seek input from a pain management service for further advice initially and at least yearly while opioid use continues.
  6. If there are any concerns about the patient developing an opioid use disorder or the person is using >200 mg oMEDD, consider obtaining input from a drug and alcohol specialist advisory service (DASAS) (Sydney metropolitan - 02 9361 8006; regional and rural NSW - 1800 023 687).
  7. Refer to NSW Health Pharmaceutical Regulatory Unit for authority to prescribe.
  8. Regular (minimum 3 monthly) monitoring and review by prescriber for functional improvement, side effects, misuse or diversion.

Safety Message

*30 mg oMEDD in older people (age >65 years) (and 1.2 mg /kg/day for children and those <50kg with chronic medical illnesses)

  1. Explain to the patient the low likelihood of long term effectiveness of opioids and known side effects and potential for serious harm even at low doses.
  2. Introduce an opioid weaning protocol.
  3. If unwilling or weaning unsuccessful, seek input from pain management service for further advice.
  4. If there are any concerns about the patient developing an opioid use disorder or the person is using >200 mg oMEDD, consider obtaining input from a drug and alcohol specialist advisory service (DASAS).
  5. Opioid de-prescribing by the general practitioner is often required after patient discharge from an acute care hospital admission. In this setting, the aim is to match the speed of opioid reduction with the process of tissue healing.
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