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Oxford University Hospitals NHS Foundation Trust

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Resources for GPs regarding opioids and chronic pain

It has become clear that opioids are not the safe and effective treatment for chronic non-cancer pain that was first thought.

The message in the 1990s, taken from experience in palliative care, was that any pain can be treated with opioids providing the dose was high enough and that the presence of pain protected against the development of addiction. Opioid prescribing increased as a result and, indeed, is increasing still. It is now clear that, although opioids provide effective analgesia for acute pain and in palliative care, there is little evidence of benefit for long-term opioids in patients with persistent non-cancer pain as regards pain, quality of life or functioning. Conversely there is now a better appreciation of the risks, including dependence and opioid-related mortality.

The British Pain Society recommends a maximum of 120mg morphine equivalent dose in 24 hours:

www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware

If the patient still describes significant pain at this dose, it can be assumed that the pain is not opioid, and the opioids should be reduced and stopped.

Although patients are now unlikely to be started on opioids for chronic pain, there is a large group of patients who have been established on long-term opioids, but who may struggle to reduce and stop their opioids. These patients are unlikely to be deriving any benefit from the opioids but are exposed to significant harm, with some on extremely high doses.

We have put together some guidance for GPs to help manage these patients:

Guidance for opioid reduction in primary care (pdf, 497 KB)

together with an opioid calculator:

Opioid calculator for calculation of oral Morphine Equivalent Daily Dose (MED) in mg/day (Excel, 17 KB)

to estimate the morphine equivalent dose, a patient information sheet and templates for opioid reduction:

where the spreadsheet will self-populate once the current dose of opioid is entered.

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