SIGN – part of Health Improvement Scotland – has updated its chronic pain advice in response to rising rates of opioid prescribing in people with long-term non-malignant conditions. Rates of such prescribing are increasing despite limited evidence of the drugs' long-term effectiveness in this setting.
In the year to 2018/19, 2.7 million prescriptions for opioids – including codeine, morphine and tramadol – were dispensed in Scotland at a cost of around £29 million. In England, the number of prescriptions for opioid analgesics nearly doubled from 14.8 million in 2008 to 23.4 million in 2018, NHS Digital figures show – with the annual cost now close to £240 million.
The updated SIGN guidance says opioids should be considered only for short- to medium-term treatment of carefully selected patients with chronic non-malignant pain, for whom other therapies have been insufficient, and where the benefits may outweigh the risks of serious harms such as addiction, overdose and death. Chronic pain is defined by SIGN as 'persistent, long-term pain lasting more than 12 weeks'.
When starting opioid treatment, the guideline advises prescribers to ensure there is agreement with the patient about expected outcomes, such as improvements in pain relief, function and quality of life. If these are not attained, then there should be a plan agreed in advance to reduce and stop opioids.
All patients on opioids should be assessed early after initiation, with planned reviews at least annually thereafter, the guideline says. Prescribers should consider gradual early reduction to the lowest effective dose or complete cessation where appropriate.
The guideline recommends patients receiving opioid doses over 50mg/day morphine be reviewed at least annually to detect emerging harms and consider ongoing effectiveness. Pain specialist advice or review should be sought for patients receiving doses greater than 90mg/day morphine equivalent.
The updated guideline follows a review of the latest evidence on potential harms from opioids. Professor Lesley A Colvin, co-chair of the guideline development group and professor of pain medicine at the University of Dundee, said: 'Opioids are powerful medicines. The purpose behind this review is to ensure that those who benefit from opioids for chronic pain continue to get the relief they need, but are also protected from potential harmful effects.
'The new evidence around potential harms and benefits has resulted in a change in our recommendations about how best to use opioids for chronic pain. Opioids should only be started after careful assessment and discussion, with agreement that benefits must outweigh risks for continuing use.
'The best evidence tells us that better management of opioid prescribing, alongside consideration of other management strategies – such as supporting increased physical activity – with increased reviewing of patients, will give patients the protection they need.'
Dr Safia Qureshi, director of evidence for Healthcare Improvement Scotland, said: 'It's important that those who need strong pain relief get the medication they need, but are kept safe from the dangerous side-effects associated with these powerful medicines. We would urge healthcare professionals to make use of the updated guideline to ensure that people get the best possible care.'