In this guest blog, Consultant in Pain Medicine Cathy Stannard and pain researcher Andrew Moore discuss some unpalatable truths about traditional opioids for chronicA health condition marked by long duration, by frequent recurrence over a long time, and often by slowly progressing seriousness. For example, rheumatoid arthritis. non-cancer pain.
What are opioids?
There are two main types of opioids. Traditional opioids, which we discuss here, are drugs that work only on opioid receptors in the nervous system; they include morphine, hydromorphone, codeine, hydrocodeine, methadone, oxycodone, fentanyl, and buprenorphine. Some opioids (tramadol, tapentadol) have additional methods of action, and need to be considered separately on another occasion.
What is chronic non-cancer pain?
If you ignore pain lasting less than three months, and headache, and cancer pain, then what you have left is chronic pain that isn’t cancer. Chronic non-cancer pain (CNCP) is typically defined as pain that is moderate or severe lasting six months or more, and includes conditions like low back pain, osteoarthritis, rheumatoid arthritis, neuropathic pain, fibromyalgia, and a range of other conditions.
People with CNCP of any sort have a lot in common – their lives are often pretty awful and they don’t enjoy it. They find it hard to sleep, they are fatigued and depressed, they struggle to work or look after the family, relationships with friends and family are strained, and they have low quality of life (the lowest of any medical condition for people living in the community). CNCP is common, and affects 10%-20% of adults, particularly older adults. Long-term opioid users with CNCP in Australia typically had their pain for 10 years or more, had low employment and income levels, were depressed, and had a 1-in-5 history of a suicide attempt.
How is CNCP treated?
Not awfully well. In chronic pain no drug treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. works well for most people; long-term opioid use is beset by problems with side effects without good evidence of long-term benefit. Prescribing effective treatments for neuropathic pain (duloxetine, pregabalin) is often discouraged at local level, even when approved for a condition and suggested by guidelines like NICE. Drugs are frequently used off-license. Switching to try and find a drug that works is uncommon.
Non-drug interventions might be useful for a few and are encouraged, but evidence of efficacyThe extent to which an intervention (for example a drug, surgery, or exercise), produces a beneficial result under ideal conditions. for most of them is scant or non-existent. For psychological therapies, some of which might have a modest benefit if delivered by trained and experienced staff, a hard-hitting Cochrane review argued for no new RCTs without considerable introspection on methods and outcomesOutcomes are measures of health (for example quality of life, pain, blood sugar levels) that can be used to assess the effectiveness and safety of a treatment or other intervention (for example a drug, surgery, or exercise). In research, the outcomes considered most important are ‘primary outcomes’ and those considered less important are ‘secondary outcomes’..
What are the prescribing trends?
The trend is for drug therapy to avoid using NSAIDs (seen to be dangerous) and some licensed medicines (seen to be expensive), with the result that traditional opioid use has soared. This is the conclusion from the most recent UK survey, but the picture is similar around the world:
“There has been a huge increase in strong opioid prescribing in the United Kingdom, with the majority of prescriptions for non-cancer pain. Morphine was the most frequently prescribed, but the utilization of oxycodone, buprenorphine and fentanyl increased markedly over time.”
Why does rising opioid prescribing matter?
Several reasons. One is cost. In primary care in England 2015 spending on opioids was £314 ($412; €364) million; that compares with the combined spending on paracetamol, paracetamol/opioid preparations, and NSAIDs of £270 ($354; €313) million. Now not all of that spending is for CNCP, but it gives an indication of the size of the problem: a lot of money for an interventionA treatment, procedure or programme of health care that has the potential to change the course of events of a healthcare condition. Examples include a drug, surgery, exercise or counselling. of marginal efficacy.
Of greater concern is the associationA relationship between two characteristics, such that as one changes, the other changes in a predictable way. For example, statistics demonstrate that there is an association between smoking and lung cancer. In a positive association, one quantity increases as the other one increases (as with smoking and lung cancer). In a negative association, an increase in one quantity corresponds to a decrease in the other. Association does not necessarily mean that one thing causes the other. of rising prescribing with rising opioid-related death, particularly in the USA, though not (so far) the UK. Dose levels with opioids can often be eye-wateringly high. It is not unusual to see people taking the equivalent of 1 gram of oral morphine a day; this dose would kill most people who have not been exposed to opioids and is five times what is considered to be a high dose in clinical practice. There are instances of daily consumption being much, much, greater. Perhaps none of which might matter if lots of people had really good pain relief. Some undoubtedly do, but high opioid consumption with high pain scores seems to be the norm.
How well do opioids work in CNCP?
A number of Cochrane reviewsCochrane Reviews are systematic reviews. In systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. try to provide answers. There have been many new reviews in the past few years, and many more are on their way. There is a sea change in approach – no longer lumping together all opioids, irrespective of drug, dose, duration of studyAn investigation of a healthcare problem. There are different types of studies used to answer research questions, for example randomised controlled trials or observational studies., or imputation method used for dropouts. New reviews are more focused – this drug, at this dose, in this condition, in longer duration studies (for a long-term problem), and highlighting problems with imputation methods because that comes with very high riskA way of expressing the chance of an event taking place, expressed as the number of events divided by the total number of observations or people. It can be stated as ‘the chance of falling were one in four’ (1/4 = 25%). This measure is good no matter the incidence of events i.e. common or infrequent. of biasAny factor, recognised or not, that distorts the findings of a study. For example, reporting bias is a type of bias that occurs when researchers, or others (e.g. drug companies) choose not report or publish the results of a study, or do not provide full information about a study.. They also look for outcomes that have clinical utility, typically the proportion of people who experience a long-term reduction in pain of at least 50% or 30%, or who have no worse than mild pain with treatment. In short, trying to provide results that are useful to people with pain and professionals trying to help them.
What these newer reviews find is that there is little or no evidence from high quality RCTs: basically, we don’t know whether traditional opioids work or not. The language used is that there is no evidence to support or refute their use. Reviews typically highlight methodological issues such as short duration, small size, and major potential bias from imputation method. In head-to-head comparisons opioids are not as good as non-opioid drugs. But we do know four important things from recent research.
- Withdrawal rates in trialsClinical trials are research studies involving people who use healthcare services. They often compare a new or different treatment with the best treatment currently available. This is to test whether the new or different treatment is safe, effective and any better than what is currently used. No matter how promising a new treatment may appear during tests in a laboratory, it must go through clinical trials before its benefits and risks can really be known. of traditional opioids in CNCP are usually high – 40% over the first three weeks, and 60% or more over 12 weeks, usually because of side effects.
- Imputation methods like last-observation-carried-forward (LOCF) are used in most trials. These take the pain score of someone who withdraws at three weeks and carries that forward to the end of the trial, as if they continued to have the same pain relief even though they are not taking the tablets. The bias can be so high that it can change a result from ‘this drug works’ to ‘this drug is no better than placebo’.
- To our knowledge, there are only two studies showing that a traditional opioid can provide good long term pain relief, but then only for about 5%-10% of people. Both have an enriched enrolment randomisedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group (the intervention group) will be given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group). withdrawal design, and are done to the highest current standards. For those who do get pain relief, oral morphine 120 mg daily does the job for most.
- Opioid adverse events are common and not innocuous. There is considerable observational evidence linking opioid use (especially high doses) to mortalitydeath, suicide, fracture, cardiovascular events, and hospital admission.
What should we do with this thinking?
Let’s be clear: there will be some people with CNCP who will and do get pain relief with opioids, and can use them in the longer term without harm, though the evidence is weak (as shown by a Cochrane review). They won’t be many and we have no way of predicting who they will be. The catch is that trial and error may lead to significant adverse events, or real difficulty stopping the opioid. Some people take heroic opioid doses, but with unrelieved pain. Getting them off opioids is very difficult, with little high quality evidence to help (as shown by yet another Cochrane review).
The aim should be to avoid high doses except in very exceptional circumstances. Daily doses above 180 mg of morphine equivalent have not been validated in trials involving patients with chronic pain. A consensus is coalescing around the suggestion that the upper limit of opioid dosing should be limited to between 50 mg and 180 mg oral morphine equivalents daily; the trend is towards lower daily dosing. Higher doses may be prescribed if benefits and risks are properly assessed, and probably under the guidance of an experienced pain physician.
Certain sorts of dosing regimens can be safer than others. Prolonged release formulations were encouraged for patients who have pretty continuous pain. But it is difficult to get fixed doses right, particularly when pain will vary in intensity depending on type and level of activity. If people are given flexibility in dosing, most will look for opportunities to avoid taking medicines when pain is more tolerable; this allows them to keep doses as low as possible.
The emerging consensus is sensible, giving people with chronic pain the chance of pain relief, but with a brake on runaway dosing, and on drug diversion. A British Pain Society pathway on the initial treatment of chronic pain has a useful mnemonic of the four-As for effective treatment monitoring:
- Analgesia (pain relief).
- Activities of daily living (physical and psychosocial functioning).
- Adverse effects (side-effects).
- Aberrant drug taking (addiction-related outcomes).
Taking sides
People with chronic pain who take opioids can be upset at the suggestion that their medicines may be withdrawn or limited. US patient blogs can be particularly vociferous; they find reviews that point out a lack of evidence of efficacy of opioids unwelcome.
The evidence is certainly untidy and unsatisfactory, and opioids will be unsuitable for many people in the longer term. The situation for opioids is no different from that of other drug and non-drug treatments where a small number of people benefit immensely, but most do not. Scrutinizing the evidence is not about taking sides – it is about finding ways where people who can benefit do, and where those who won’t are protected from risk.
The core message is stark. Opioids are dangerous and often expensive drugs. They should be started only with caution and with upper dosing limits, and continued only with demonstrably reduced pain – ideally to mild or no pain. If the opioid isn’t working after a decent trial – six weeks should be enough –it should be stopped. People already on opioids are often unsure if opioids are working or not, but they are certainly still in a lot of pain. They should be encouraged to slowly and safely reduce the dose to get a better idea of how helpful the drug is for their pain.
Cathy Stannard has nothing to disclose. Andrew Moore reports grants and personal fees from RB, grants and personal fees from Gruenenthal, personal fees from Menarini, grants and personal fees from Novartis, personal fees from Futura, personal fees from Omega, outside the submitted work.
Page last updated 21 August 2020
This is why I can’t get my morphine back it was the only pain med that worked was on it for 10 yrs had my life back now I’ve been taken off 8 yrs ago and 3 yrs ago broke my femur now have rods in that really hurt can’t take NSAIDs due to bleeding ulcers and ulcers as well as IBS my life is a living hell and I so want to end it as nothing else works don’t like Percocet either or hydromorphone diladin they don’t work just the regular morphine works for me most times I would only take one a day then other days my 3 a day but I can’t get it back now I just want to die as I have no quality of life anymore
So sorry that things are so tough for you. I’m sorry not to be able to offer anything helpful but my colleague Selena and I wanted to let you know that you’ve been heard. I imagine there are others reading this blog who will identify with your story too. Thank you for posting.
Very best wishes,
Sarah Chapman [Editor]
The constant/mildly fluctuating aspects of my chronic pain can be fairly well controlled using pain management methods such as CBT, pacing, heat, stretching and physio, and I’ll be forever grateful for the Pain Management Programme I was sent on through the NHS. I’ve also had various different types of physio, massage, and osteopathy, all of which have helped. However, the two more acute manifestations of my chronic pain, sciatica and acute back spasms, while somewhat mitigated by the above, require further treatment. I’ll focus on the back spasms, as they’re the most disabling part of my chronic pain.
When I do too much (standing, sitting, walking, etc. for more than 5-15 minutes), stay in one position (for longer than 5-20 minutes), and sometimes for no reason whatsoever, my lower back, upper buttock, hip and thigh go into spasm. The muscles contract to the point that my mobility is limited, anywhere from being able to walk short distances crouched over in a lot of pain to being unable to stand without help. They happen 0-5 times a week (2-3 on average), and last anywhere from minutes to 9 days (usually 5 hours – 1 day). The pain ranges from 6/10 to 9.5/10.) (The 9.5/10 spasm landed me in hospital for 5 days of IV morphine and benzos a few years ago.)
I don’t catastrophise – I know the spasms aren’t causing me further damage – but they’re f***ing agonizing, and they lay me up for hours to days. It takes further hours to recover from the resultant stiffness and fatigue, too. Very occasionally I say, “Screw it”, take all my meds, put on a hot pack and my TENS, and do something normal, but oh do I suffer for it. My life is really limited by whether or not I’m willing to risk a spasm, and working is impossible. Who’s going to hire you if you’re going to disappear randomly for random amounts of time, possibly not be able to make deadlines, and need to work from home with very flexible hours?
I’ve had injections into my epidural space, my facet joints, and another spot (forgotten). I also had a radiofrequency denervation of my L3/L4-L5/S1 facet joints. All helped, but only for a few months..I’m on gabapentin and an antidepressant for my chronic pain, and very occasionally I take paracetamol and NSAIDs. (8 years ago I suffered acute kidney failure due to paracetamol (pain doc didn’t mention that 4g/day should only be taken short-term) so I avoid paracetamol most of the time now. I also developed severe stomach problems and GERD due to my use of NSAIDs. Diclofenac (without any stomach protecting meds – bad GP), followed by naproxen (better, but caused more damage) left me with an ulcer and a very, very delicate tum. I occasionally take ibuprofen when I feel an abnormal amount of stiffness, but I avoid NSAIDs most of the time. I still take omeprazole and nexium, and suffer with GERD despite limiting my diet.)
By far the most useful treatments for my spasms are tramadol.and diazepam. I take tramadol when I feel a spasm starting, and when an existing spasm gets above 7.5/10 I add diazepam. On the odd occasions when tramadol + diazepam aren’t enough to cut the pain down to an acceptable level, I take oral morphine, but I only take that if I absolutely have to. (I’ve never *wanted* tramadol. It’s a medicine, and I take it when I need it. Morphine, on the other hand, quickly results in thoughts of, “Oooh, it’s almost time for more morphine!”. Scary. Last thing I need is an opiate addiction.) Without the tramadol and benzos, spasms would be absolute hell. I’ve occasionally run out of tramadol when away from home and had to go through a spasm without it, and NONONO. I will not do that on a regular basis. Life is not worth that much pain on a regular basis.
I also tramadol before doing something that’s likely to seriously raise my chronic pain levels and/or trigger sciatica/a spasm (sweeping the kitchen floor, walking to the corner shop, sitting on a hard chair for half an hour – yes, I know). The tramadol often stops a spasm from occurring, or at least lets me do more before it happens. Without the tramadol, I’d do even less than I do now.
I’m doing cardio, lots of physio, relaxation exercises, pacing pacing pacing, TENS, heat, goal-setting, stretching, meditation, mindfulness, looking into acupuncture, getting occasional massages from friends, and investigating botox injections, but tramadol is what makes my life bearable (during spasms) and possible (the rest of the time). Sometimes I don’t need it for a day or 3. Usually I don’t even notice that I haven’t taken it, although during bad periods I can get a bit sweaty and irritable. It’s fine. I don’t want to take it – I just notice the withdrawal and carry on.
Please please please, don’t take opioids away from people like me. Tramadol is what makes my life worthwhile (I know, that sounds so much like an addict talking, but read my whole comment for why). I honestly doubt that I’d stick around for very long if I didn’t have a replacement that helped as much. Life in bed, twisting in agony, just isn’t worth it.
Thanks for an interesting article.
I have been suffering from myalgic encephalomyelitis for 5 years. After 2-3 years i started to suffer from an increasing pain in my arms and legs. Usually when I wake up there’s not much pain, but at the end of the day the pain is extreme. The only way to reduce the pain is by doing nothing at all. No activity decreases the pain. Pain starts to develop when I use my arms to read a book, use my computer or my phone. Even eating leads to pain in my arms.very
I have tried every single NSAID without no decrease in pain. I’ve tried tricyclic antidepressants. They work, but they make me extremely tired. My doctor wasn’t keen on trying gabapentin because of the side effects. Last resort was Oxycodone IR. 10mg taken every night, or every other night. Made me cope with the pain in the evening, and also made it possible for me to sleep. That schedule worked fine for a year or so. The pain has been increasing since then, and my doctor decided to try out 10mg of Oxycontin ER two times a day. They help, but I still have pain in the evening. More than I had when I took 10mg of instant release. I think the next step is 10 mg in the morning, and 15 mg taken every evening.
Before I was put on Oxycodone my life was a real nightmare. Taking Oxycodone in the proper dosage can reduce my pain with 70-90%. I’m not sure how life with be without them.
Please do comment if anyone has other options that I should consider trying out.
Really enjoyed reading this article, informative and level headed in an emotive area. It must be increasingly difficult for clinicians to sensibly manage a patients pain when almost every patient has today’s access to both information and other opinions via the internet, and it always amazes me how people will believe an anonymous comment online and disregard the qualified professional in front of them they have known for years.
I know from personal experience that proving the real efficacy of pain relief medication is difficult, just look at how effective placebo can be in some trials, but this shouldn’t stop people trying with high quality RCTs, and as said in the article LOCF can be so misleading, but is often used, the key of course is to be aware of it and how it may effect the results.
The final paragraph of this article makes so much sense.
Having for many years lived with, worked with and delivered lay courses and training for people with chronic pain, I am more convinced than ever that medically treating pain without considering the psychological aspect is missing an opportunity. If someone believes that Ibuprofen does not have any effect on ‘their pain’ it probably won’t – if someone else believes that a white pill does have a beneficent effect… etc.
Drs can run out of prescribing options after increasing the medication dosages until they have reached the maximum. (Patients can and will flout that maximum and self-dose more than the maximum – I know I have on occasion – or swap pills with friends and neighbours taking pills they have not been prescribed and do not tell their Dr about)
When all other options have been used up, some people will find out about or be signposted to self-management. The gap between diagnosis and being ready for self-management can be up to 8 years – 8 years of Dr and patient trying all the medical options available, hoping for the magic bullet pill and as each one fails the patient slowly losing confidence and quality of life.
If self-management were seen as an intervention rather than a ‘when all else fails’ option, the burden on Drs and patients and clinics could be reduced.
All I can say is that my life was more fulfilling, less painful and I was able to function better, sleep better and get more done while I was taking Tramadol, without any need for an increase, except temporarily, because of another injury But only your evidence matters! That’s were your wrong!