spring 2013

c l i n i c a l   p r a c t i c e
Heard it all on opioids?


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In treating severe cancer pain, opioids are a good option. The benefit outweighs potential adverse events. Use of opioids in other chronic conditions is more controversial.

By Ms. Sarah Berglas

In treating severe cancer pain, opioids are a good option. The benefit lack of analgesia ceiling with full agonists outweighs potential adverse events, such as respiratory depression, increased sensitivity to pain, endocrine dysfunction, drowsiness, constipation, tolerance, dependence, and addiction.

Use of opioids in other chronic conditions osteoarthritis, low back pain, and fibromyalgia is more controversial. There has been a recent focus on opioid diversion, misuse, and overdose. Less readily discussed is the efficacy of opioids in non-cancer, chronic pain. With 17% of Newfoundlanders experiencing chronic pain, such a discussion is needed.

Essentially, little data exists. Explained by Dalhousie University’s Academic Detailing Service, of the 65 RCTs found to inform Canadian guidelines on this topic, half of the studies were six weeks or shorter. The longest was 16 weeks. In 33 studies, more than 30% of participants withdrew due to poor efficacy or intolerable adverse events. Importantly, 51 studies had placebo for a control group rather than first-line treatments such as acetaminophen, NSAIDs, or exercise.

Based on this limited evidence, opioids have a moderate effect on pain relief (reduction of 10% to 20% on the pain scale), compared with placebo, in patients with non-cancer, chronic pain. Regarding harms, many people could not tolerate opioids and aberrant behaviour was found to occur in 0% to 44% of study participants.

Physicians need to know what evidence exists, or doesn’t, to make informed decisions. The Canadian Agency for Drugs and Technologies in Health (CADTH) have recently prepared several evidence-based Rapid Responses reports addressing questions posed by health care decision-makers on the topics of effective opioid prescribing, preventing misuse, and managing opioid addiction. Visit the CADTH website for more information.

Sheila Tucker is the CADTH Liaison Officer for Newfoundland & Labrador.

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Nexus is published quarterly for Newfoundland and Labrador's physicians. It is a forum for the exchange of views, ideas and information for members.