Chronic non-cancer pain

Editor, – Surely in his reply to Dr Vanlint (Aust Prescr 2012;36:184-5) Dr Cohen who wrote the article on prescribing for persistent non-cancer pain (Aust Prescr 2013;36:113-5) would not be endorsing the long-term use of opioids for chronic non-cancer pain in residential aged-care facilities as the quality use of opioid medicines. Any insinuation that long-term opioids are effective or safe for chronic non-cancer pain lacks evidence¹ outside industry-funded research or guidelines. The practice may increase patient suffering by sentencing our patients to opioid-induced hyperalgesia, tolerance and withdrawal. These latter two problems have recently been determined to be physiological and not contributing towards the definition of dependence.² 

In a US observational study in the elderly, the all-cause mortality hazard ratio of opioids was 1.87 compared to non-selective non-steroidal anti-inflammatory drugs with increased risk of falls, fractures, cardiovascular events and acute renal injuries.³

Those with heroin dependence rarely make it to residential aged-care facilities, but I have had two people on methadone programmes admitted for care through their final illnesses, including one who continued injecting during visiting hours. Nursing staff found illiberal opioid provision challenging.

The current increase of opioid use in residential aged-care facilities puts pharmacists and nursing staff at risk during supply and storage. Even their disposal may lead to 'dumpster diving' or fossicking for discarded opioid patches.

Opioids do not cure chronic non-cancer pain. They frequently usurp quality multimodal care as outlined in Dr Cohen's article which may include psychotherapies and physical therapies such as Tai Chi.⁴ Whether or not 'addiction is not an issue in the elderly', long-term opioids should be avoided in chronic non-cancer pain as they are ineffective, may increase pain and cause morbidity and mortality.

Simon Holliday
General practitioner
Taree, NSW
Part-time Staff specialist
Drug and Alcohol Clinical Services
Hunter New England Local Health District

Milton Cohen, the author of the article, comments:

It is clear from Dr Holliday's language – 'insinuation that long-term opioids are effective' and 'sentencing our patients' – that he takes a very strong anti-opioid stance in the management of chronic non-cancer pain. I do not argue that this is unjustified, especially given the great difficulty in actually performing studies to determine the long-term effectiveness of opioids in this context.

However, I would argue for a pragmatic perspective. Chronic non-cancer pain is not 'curable' and a multimodal approach to management is likely to be associated with a better quality of life for the patient compared with a single modality drug-based approach. In my article, the importance of reducing distress by controlling symptoms was emphasised, as was the principle that drug therapy – any drug, including opioids – is an ongoing trial of therapy.

In this area, there is a tension between inappropriate prescriber behaviour and unsanctioned user behaviour.⁵ Dr Holliday's example of the latter is indeed distressing and challenging and may well be a consequence of inappropriate prescribing. This is all the more reason for disseminating pragmatic principles for prescribing.⁶ In the hands of a conscientious, well-informed prescriber, why should a resident in an aged-care facility be denied a trial of opioid under these principles? Given the limited therapeutic options in this population, surely this is an opportunity for the quality use of medicines.