USE OF OPIOIDS FOR THE TREATMENT OF CHRONIC PAIN
The principal obligation of the physician in the treatment on pain is first, do no harm, and then whenever possible, to relieve pain and suffering.
Opioid analgesics are potent and effective medications that relieve pain. In some patients, the therapeutic use of opioids may result in physical dependence and/or addiction.
Addiction in the context of pain treatment with opioids is characterized by a persistent pattern of opioid use that may involve any or all of the following:
- Continued use of opioids in spite of adverse consequences associated with the Use of opioids.
- Loss of control over the use of opioids.
- Preoccupation with obtaining opioids, despite the presence of adequate analgesia.
- Denial on the part of the patient that a problem exists.
Repeated exposure to opioids in the context of pain treatment does not, by itself, cause addiction. There is a variety of biological, psychological, social, and spiritual factors that may increase the risk of addiction in susceptible patients who are prescribed opioid therapy. Tolerance to the analgesic effects of opioids may occur with regular therapeutic use in some patients. Most people taking opioids regularly will have characteristic withdrawal symptoms upon abrupt cessation. Neither of the phenomena, by themselves, is diagnostic of addiction.
The etiology, presentation, assessment, and treatment of acute pain differ from that of cancer pain and also from that of chronic non-cancer pain (CNCP). Opioid analgesics are one of a variety of pharmacological and non-pharmacological therapeutic interventions used to treat pain. They have an established role in the treatment of acute pain and cancer-related pain, and more recently have been advocated for some patients with intractable CNCP. In many patients, CNCP can be managed effectively without opioids. Since pain is a subjective phenomenon, it is often a difficult clinical judgment as to whether or not opioid therapy might benefit a particular patient with a particular pain syndrome. The majority of patients treated with long-term opioids are at low risk of addiction. Patients with addictive disorders or with the potential for addiction present additional risks when prescribed opioid medication. The decision to prescribe opioids to theses patients requires extra caution, additional expertise, and a level of comfort on the part of the physician.
Despite appropriate medical practice, competent physicians may occasionally be misled by skillful patients who wish to obtain opioid medications for purposes other than pain treatment, such as diversion for profit, recreation, abuse, or maintenance of an addicted state. It must be recognized that physicians who are willing to provide compassionate, ongoing medical care to challenging psychosocially stress patients may more often be face with deception than physicians who decline to treat this difficult population.
Medical training has traditionally provided little education in addiction and pain management. This omission is not a reason for inadequate treatment of pain and/or inadequate treatment of addictions by those physicians who choose to prescribe opioids for the treatment of pain.
Therefore, The Canadian Society of Addiction Medicine endorses the following:
Policy On The Use Of Opioids To Treat Pain
Addiction to opioids may occur in the course of opioid therapy of pain in susceptible individuals under some conditions. The decision to prescribe opioid therapy for a patient in pain is a medical judgment based on careful biopsychosocial assessment, which includes an assessment of risk factors for addiction. All patients in whom long-term opioid therapy is prescribed as part of the treatment plan require careful ongoing monitoring. If an addiction disorder is pre-existing or is uncovered during the course of treatment, appropriate addiction assessment and treatment needs to be provided together with appropriate pain management. Opioid therapy may still be beneficial for those patients but requires extra caution and monitoring.
Recommendations:
- Physicians who choose to prescribe opioid analgesics are obligated to have obtained an appropriate level of knowledge, training, and experience to enable them to apply the principles of good medical care to the treatment of pain.
- Physicians who prescribe opioids for the treatment of pain must perform a comprehensive assessment to establish that a pain state exists and to determine whether of not opioids are an indicated component of treatment. Opioids need to prescribed in a legal and clinically sound manner. Patients need to be followed at reasonable intervals for ongoing medical management and to confirm, as nearly as is reasonable, that the medications are being used as prescribed. Such management needs to be appropriately documented in the patient’s medical record.
- Physicians who use reasonable medical judgment regarding the prescription of opioids for the treatment of pain must not be held responsible for the willful and deceptive behavior of patients who successfully obtain opioids for non-medical purposes. It is the appropriate role of the regulatory bodies and pharmacies to inform physicians of the behavior of such patients. Physicians who consistently fail to recognize addictive disorders in their patients need to be offered education, not sanction, as a first intervention. Similarly, physicians who consistently fail to appropriately evaluate and treat pain in their patients need to be offered education as a first-line intervention.
- For the purposes of performing regulatory, legal, quality assurance, and other clinical case reviews, it should be recognized that judgment regarding: a) the medical appropriateness of the prescription of the opioids for pain in a specific context; b) the selection of a particular opioid drug or drugs, and c) the determination of indicated opioid dosage and interval of medication administration, can only be made properly with full and detailed understanding of a particular case.
- Regulatory, legal, quality assurance and other reviews of clinical cases involving the use of opioids for the treatment of pain should be preformed, when they are indicated, by reviewers with a requisite level of understanding of Pain Medicine and Addiction Medicine.
- Appropriate education in Addiction Medicine and Pain Medicine should be provided as part of the core curriculum at all medical schools.
Adopted October 2000