B-QuiCK: Opioids

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Prescribing opioids

Indications for opioid prescribing include

  • Moderate to severe acute pain following surgery or injury (short-term use preferred)
  • Moderate to severe cancer-related pain or pain associated with terminal-conditions (palliative care)
  • Moderate to severe chronic non-cancer pain for selected patients in whom pain cannot be controlled despite the use of non-opioid analgesics/other non-pharmacological interventions, and which is adversely affecting functioning and quality of life (short-term or intermittent use preferred). The decision to initiate longer periods of opioid use should only be made when there is a documented benefit (e.g. improvements in pain score or function) that outweighs potential harms, and ideally be made in consultation with a multi-disciplinary pain management team*.
  • * This recommendation is based on evidence from clinical trials, however, we acknowledge that it is not always practical due to resource limitations.

Key recommendations for opioid prescribing in primary care

  • Establish a treatment plan when initiating an opioid, including measurable goals and the timeframes for achieving these, information about adverse effects and a plan to stop use. This jointly agreed plan can be verbal, but it should be documented in the patient notes.
  • To access an editable pain management plan template, click here

In some cases, a formal written and signed opioid contract may be suitable to ensure safe and effective opioid use, e.g. when strong opioids are prescribed and there are concerns over the potential risk of misuse or dependence. Click here to access an example opioid contract if you think it might be suitable for a specific patient.

  • Ideally select an immediate release formulation due to the lower risk of sedation, respiratory depression and overdose (particularly during initiation). Modified-release opioids are a strong risk factor for opioid dependence. N.B. modified-release formulations may still be considered in certain scenarios depending on clinical judgement.
  • Use the lowest potency and dose possible to effectively manage pain. Reassess the benefits and risks of treatment when considering each dose increase if pain is insufficiently controlled.
  • Prescribe in combination with non-opioid analgesics and/or adjuvant medicines as this may reduce the dose of opioid required to achieve pain relief (due to different modes of action)
  • If initiation of a strong opioid is being considered in primary care, ensure morphine is trialled first before prescribing oxycodone (unless the patient has a documented allergy or intolerance)
  • Prescribe for the shortest possible duration (ideally three days or less). If this is not practical and longer-term use is required, advise intermittent dosing (i.e. as-needed within the daily dosing limits), rather than continuous use. Intermittent dosing reduces the risks of treatment without compromising potential benefits.
  • Prescribe a laxative if use will exceed 2 – 3 days duration and advise patients to remain hydrated
  • Be alert for potential signs of misuse and dependence, e.g. requests for early repeats or escalating doses
  • If longer-term use is required, check in with the patient at each new prescription to assess the need for continued use. The opioid dose or potency should be gradually titrated down as pain improves (as per treatment plan). For further information, click here

Live Well with Pain is an initiative developed by clinicians in the United Kingdom. It includes a comprehensive suite of freely available resources designed to inform and support health professionals working with patients who have persistent pain and to help guide the appropriate use of opioid medicines. For further information, see: https://livewellwithpain.co.uk/

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