1. Opioids for the management chronic non-cancer pain in Primary Care:
Potential, perils and pitfalls
All Party Parliamentary Group for Prescribed Drug Dependence
Dr George Ryan Former GP
Clinical Advisor to Public Health England

2. 16/05/2018
Opioid analgesic prescribing for chronic non-cancer pain in primary care
What’s the problem?
What patients need to know
What doctors need to know
Principles and practicalities of good practice

3. Number of patients prescribed opioid analgesics for chronic non-cancer pain in UK primary care
Zin C et al. Eur J Pain 2014; 18: 1343 – 1351.
Most opioid analgesics don’t work for most patients with CNCP British Medical Journal June 2013

4. Side effects of opioid analgesics
Constipation
Nausea
Sedation
Cognitive impairment
Depression
Hormonal changes
Dependence
Addiction
Respiratory depression
Hyperalgesia

5. Increased risk of: Sexual dysfunction [OR 1.45 (CI -1.87)]
16/05/2018
Increased risk of:
Sexual dysfunction [OR 1.45 (CI -1.87)]
Fractures [OR 1.27 (CI )]
Myocardial infarction [OR 1.28 (CI )]
Abuse [wide range – up to 37%]
Overdose [HR 5.2 (CI )]
Motor vehicle accident [OR ]
Death—especially above daily morphine equivalent of 120mg
Chou R et al. Ann Intern Med 2015; 162: 276.

6. Pain and suffering Impairment Poor mobility Depression Irritability
Isolation
Rumination
Impact on partner, family, carers
Perceived as “heartsink” patients

7. What patients need to know
Opioids..
..rarely help chronic non-cancer pain
..cause numerous side effects
..can cause dependence
..can cause addiction
..can cause premature death
..if not working they should be reduced and stopped

8. What doctors need to know
Opioids..
..rarely help chronic non-cancer pain
..cause numerous side effects
..can cause dependence
..can cause addiction
..can cause premature death
..if not working they should be reduced and stopped

9. Principles of good practice
16/05/2018
Principles of good practice
WHO analgesic ladder unhelpful for chronic non-cancer pain [CNCP]
Use non-opioid analgesics for CNCP
If opioids are used, prescribe the lowest possible dose
If opioids are used exercise caution and arrange early and frequent review
Do not initiate a medication if you are unable reduce or discontinue it
Provide advice and support about reduction and cessation of opioid analgesics
If necessary, prescribe medication for symptomatic treatment of withdrawal symptoms
Commission primary care based services to manage dependence or use disorder
Promote pharmacovigilance

10. DREAMS Dialogue Realistic expectations Equivalence of esteem
Avoid over-medicalisation
Menu of options from Acupuncture to Zen
Support self-efficacy