Opiates are an effective pain-killer, with a proven track record in treating cancer pain.

The use of opiates to treat chronic non-cancer pain (CNCP) is both more recent and more controversial. Opiate prescriptions rose 300 percent between 1992 and 2007. As of 2016, opiate use continues to rise.

In 2013, Simon Holliday, an Australian GP and addication specialist, wrote a paper outlining what is known, and what is unknown, about the use of opiates to treat CNCP. 

After reviewing opiate use studies for CNCP from the past decade, Holliday concluded that there is little evidence that opiates substantially decrease pain levels or increase function for CNCP patients.

Opiate use has been linked with adverse effects, including nausea, dizziness, drowsiness and sleep apneas. Misuse can also lead to addiction and overdose. Of the 705 opiate overdose deaths in Australia in 2010, 70 percent were caused by the prescription medications morphine or oxycodone.

In the US, a study showed that only 19 percent of people on prescription opioids used them as prescribed. Forty-three percent self-medicated, 27 percent used recreationally and 18 percent used chaotically, showing a dependency on the drug.

Clearly, there are dangers associated with the increased availability of prescription opiates. However, Holliday says that GPs can take steps to minimize the risks when treating CNCP.

• Implement a Practice-wide Protocol:
  
  Holliday advises medical practices to devise a protocol for prescribing opiates. This could include refusing to provide opiate prescriptions on a first appointment to prevent patients “shopping around”. It could also require all GPs to check injection sites, contact the patient’s previous GP and order a drug test.
   
• Identify Risk Factors:
  
  When compiling a clinical history, doctors should include risk factors for potential drug abuse. Holliday describes this as a “biopsychosocial” approach.
  
  The doctor should conduct a psychiatric evaluation, bearing in mind that depression can exacerbate pain. Drug and alcohol history should always be requested, with a particular focus on any addictive behaviours. The physical examination should aim to clarify the source of the pain to determine what treatment is appropriate.
   
• Consider Non-Opioid Strategies:
  
  Medication is not the only option for alleviating chronic pain. A multidisciplinary approach can be highly effective in pain management by treating both the body and the mind.
  
  Yoga, relaxation therapies, acupuncture and cognitive behavior therapy can all help reduce pain. Pharmaceutical non-opiate strategies, like paracetamol or omega-3 fish oil, could also be trialed.
   
• Monitor Patients on Opioids:
  
  If the doctor concludes that opioids are the best treatment for the patient, proper management can do a lot to minimize harm. The doctor could devise a management plan tailored for the specific patient. The plan should require full disclosure of the risks of opiates and consistent psycho-emotional monitoring.
  
  If possible, opiate treatment should be time-limited. The doctor should continue to monitor the patient at each appointment by asking about the four As: analgesic effect, activities of daily living, adverse reactions, and aberrant behaviours. Then, if use does become problematic, doctors should wean patients off opiates gradually rather than terminating use abruptly.

Opiates are a powerful pain-killer with the potential to ease the suffering of those in chronic pain. However, they also have the potential to harm. Tighter controls by doctors could have a major impact on whether opiates alleviate a patient’s struggles or simply add to them.

If you'd like to read Simon Holliday's paper in full, you can find it online here.