In May 2017, the Canadian Medical Association Journal published new opioid therapy recommendations for chronic non-cancer pain. (The recommendations do not apply to acute pain, such as a broken bone or after surgery, and they do not apply to pain associated with cancer.)
It is estimated that 15 to 19 per cent of Canadians live with chronic non-cancer pain, for example chronic back pain, and it is this type of pain that these recommendations address.
Reduced quality of life and poorer functioning go hand-in-hand with chronic non-cancer pain, but treatment with opioids seems to provide little benefit while introducing many potential problems, ranging from dependency to overdose and death.
Opioids were originally obtained from the opium poppy plants, but today most are manufactured in pharmaceutical plants. Opium is Greek for “juice,” referring to the extract that has been used for centuries.
Opioids include drugs like morphine, codeine, hydromorphone, and oxycodone, all of which have similar effects to the original opium “juice.”
Opioids interact with pain receptors to produce their analgesic effects, but they also affect other receptors in the nervous system and brain to produce adverse effects.
Ideally you want the pain relief without any of the other effects. A “high” or euphoria is an adverse effect that results in dependency and addiction, in that you continue seeking the drug in order to experience the effect. And, if you try to stop, you experience withdrawal symptoms.
Unfortunately, opioids also cause respiratory depression which means you stop breathing and can die.
The recommendations are aimed at using the minimal effective dosages of opioids for chronic non-cancer pain and depending more on other pain management strategies. The recommendations are classified as strong and weak, with the former being considered the standard of practice.
Strong recommendations include optimizing non-opioid therapy and non-drug therapy first, before beginning opioid pain relievers. Non-opioid therapy includes drugs like acetaminophen; non-steroidal anti-inflammatory drugs, for example ibuprofen, naproxen, diclofenac, celecoxib; and adjunct drugs, for example amitriptyline, doxepine, and duloxetine.
Numerous non-drug approaches exist and often a combination of one or more with a non-opioid drug or drugs provides effective pain relief, for example physical therapy, weight loss, psychological counselling, massage, exercise and relaxation techniques.
Obviously, if an existing substance abuse problem is present, it is a strong recommendation to not use opioid analgesics. And, if an opioid analgesic is begun, it should be at a maximum dose of 90 mg morphine equivalents daily.
“Morphine equivalents” are how the potencies of opioids are compared to each other. Hydromorphone and oxycodone are both more potent than morphine with the equivalent doses being 18 mg and 60 mg respectively. Codeine is less potent and its equivalent dose is 600 mg.
Weak recommendations are those that the majority of people would consider appropriate, for example a lower daily recommended dose of 50 morphine equivalents, titration of higher daily doses down to lower doses, and stabilization of any psychiatric disorder before a trial of opioid analgesics is tried.
Perhaps in future recommendations, these may become standards of care.
The adage “a pill for every ill” doesn’t seem true with opioids and non-cancer chronic pain. The best approach seems to be non-drug and non-opioid.