Opioids in chronic non-cancer pain

  • Kevin Vowles

    Professor of Clinical Health Psychology, School of Psychology, Queen's University, Belfast, United Kingdom
  • Winfried Häuser

    Adjunct Professor, Department Psychosomatic Medicine and Psychotherapy, Technical University Munich, Germany Senior Physician, Department Internal Medicine, Germany
  • Nevenka Krcevski Skvarc

    Assistant Professor, Anesthesiology, Pain Medicine and Palliative Care, Faculty of Medicine of University Maribor, Slovenia
  • Geert Dom

    Antwerp University, Belgium European Federation of Addiction Societies (EUFAS), Belgium

Chair: Kevin Vowles, United Kingdom
New European clinical practice guidelines
Winfried Häuser, Germany
The European Clinical Practice Recommendations (ECPR) define a very limited role for opioids in the management of CNCP. Opioids should not be considered for primary pain syndromes (nociplastic pain mechanisms) such as primary headache (e.g. migraine), functional somatic disorders (e.g. fibromyalgia), chronic primary visceral pain (e.g. irritable bowel syndrome), primary musculoskeletal pain (e.g. non-specific low back pain) and pain as a major manifestation of a mental disorder (e.g. somatoform pain disorder). Opioids can be considered for chronic secondary pain syndromes after optimization of non-pharmacological or non-opioids and if established non-pharmacological/non-opioid treatment is:
  • Not effective and/or
  • Not tolerated and/or
  • Contraindicated
  • Not available
Evidence-based potential indications are low back pain with predominant nociceptive/ neuropathic mechanisms, osteoarthritis pain, diabetic polyneuropathy and postherpetic neuralgia. Based on expert opinion, the ECPR lists some other chronic secondary pain syndromes which can be a candidate for opioids. Measure prior to the initiations of opioids include screening for mental disorders and specialist assessment, if mental disorder is indicated as well as setting individual and
realistic therapeutic goals (improvement of daily functioning, 30% pain relief). Opioids should be started at a low dose (e.g., <50 mg morphine equivalent [MEQ]/d) and increased in a stepwise manner to reach therapeutic goals. 90 mg MEQ/d should only be exceeded in exceptional cases. Longer than 3 continuous months of opioid prescription should only be considered in treatment responders. Regularly review (every 1-3 months) for maintenance of therapeutic goals, indications for adverse events and evidence of opioid use disorder or misuse are recommended. 
In the titration phase, stepwise discontinuation should be considered, if individual therapeutic goals are not met or if intolerable side-effects occur. Discontinuation of long-term opioids should be considered, if herapeutic goals are no longer achieved, itolerable adverse events occur, other treatments achieve therapeutic goals, urine drug tests are refused, or opioids are used in an abusive manner.
New European Clinical practice guidelines: Part II
Kevin Vowles, United Kingdom
In 2019, EFIC comissioned a task force to provide European Clinical Practice Recommendations with regard to opioids for chronic noncancer pain (CNCP). Three overarching domains for recommendations were identified: (1) The role of opioids in the management of CNCP, (2) Good clinical practice guidelines, and (3) Recommendations for special situations. This presentation will provide an overview of the third domain and represents a continuation of the previous presentation covering the first and second domains. Eight sets of recommendations for special situations will be discussed, including differential indications for opioid selection, opioids in combination with other centrally acting medications, opioid use in special patient groups (e.g., older adults, homeless and incarcerated individuals), use in those with comorbid conditions, management of complications, and considerations to identify and manage opioid abuse and misuse. Although the evidence-base in this area is limited and generally weak, there was generally excellent consensus amongst task for members. These gulidelines for special situations therefore represent a consensus statement of healthcare professionals who work with those who have chronic pain.
Management of side effects of opioids
Nevenka Krcevski Skvarc, Slovenia
Opioids are useful drugs for managing acute and chronic pain; however, side effects are potential limitations for their use, especially in long-term use. Between 50 – 80% of patients experience at least one side effect from opioid therapy. Side effects frequently lead to discontinuation of opioid therapy. When prescribing them, an understanding of the risk and benefits is essential. Appropriate explanation about opioid side effects and about their management should be provided to all patients.
Most side effects are predictable consequence of opioid pharmacological action and some improve shortly after initiation of treatment. Strategies to minimize side effects of opioids include dose reduction, symptomatic management, opioid rotation and changing the route of administration. Sometimes discontinuation of therapy is the option, too. 
Side effects of opioids can be present in all systems of the body being the most frequently in gastrointestinal system. In this system the most present are constipation and nausea. While nausea usually disappears in one to two week and only sometimes needs treatment with prokinetics, setrons, neuroleptics or antihistamines, constipation presents continuous side effect in majority of patients and needs prophylactic measures and treatment. The step approached treatment with laxatives, local opioid receptor antagonist and change of application rote is used. Sedation and cognitive changes usually occur with initiation of therapy or dose escalation: the measures to alleviate them are dose reduction and opioid rotation. Underlying renal or liver disease or concomitant use of centrally acting medications can contribute to side effects of opioids. Adjustment and choice of opioid are needed as well as special care. The concomitant use with tranquilizers is not recommended and special care is needed when used with gabapentinoides, antidepressives and anticonvulsives.
The incidence of side effects such as opioid induced hyperalgesia, muscle rigidity, myoclonus, immunological disfunction, hormonal dysfunction, physical dependence, tolerance and addiction is not well known. They are usually side effects in long-term use of opioids. In the case of tolerance, opioid rotation or dose escalation is needed while in opioid induced hyperalgesia opioid must be reduced. Hormonal dysfunction may need substitutional therapy. Myoclonus can be predictor of opioid intoxication; dose reduction is needed.
When problematic use of opioids is noticed, interdisciplinary treatment is advised, usually accompanied with opioid tapering.
Opioid analgesia is accompanied by undesired side effects which must be recognized, prevented and adequately managed to ensure safe opioid treatment.
The perspective of addiction medicine
Geert Dom, Belgium

Two important health related developments have characterized the last two decades within Western Europe and the US. On the one hand the continuous increase in the number of patients suffering from chronic non-cancer pain. On the other hand, a continuous increase in the prescription of opioid medications. As to the latter, this has contributed to the “opioid epidemic” in the US, of which the impact on morbidity and mortality represents a substantial public health crisis. Although in Europe these evolutions to seem to take a milder course, it cannot be denied that the last decade in many countries the number of opioid prescriptions increased exponentially. Most of these prescriptions have been initiated in the context of the treatment of chronic non-cancer pain (CNCP). Of importance, for a substantial number, estimated arround 10%, of CNCP patients long-term opioid treatment might represent a risk for abuse, diversion and possibly full blown addiction. Thus, taking an addiction perspective in addition to the pain management perspective is needed when considering (long-term) opioid treatment for CNCP patients. Within the management guidelines of CNCP patient guidance needs to be incorporated to help clinicians in their clinical decision making. These elements involve screening on potential addiction risk, diagnosing substance use disorders, prevention and treatment of concurrent substance use problems.


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