Prescribing opioids for chronic noncancer pain

Opioids have a limited role in the management of chronic noncancer pain and can cause serious harm, see The role of opioids in chronic noncancer pain. Prescribers must carefully consider, and justify, the rationale for conducting an opioid trial for chronic noncancer pain—one clinician or team should be responsible for prescribing the opioid and reviewing efficacy.

For children and adolescents with chronic noncancer pain, seek specialist advice before considering an opioid¹.

Note: Seek specialist advice before trialling an opioid for chronic noncancer pain in children and adolescents

If a short-term trial of an opioid is appropriate in adults (see Initiating analgesics for chronic noncancer pain), buprenorphine patches, or oral morphine, oxycodone, tapentadol or tramadol may be considered.

All opioids have similar efficacy for chronic noncancer pain. The choice of opioid requires consideration of the context in which the opioid is being used, specific properties of the opioid (see Overview of opioids commonly used in pain management), and any previous response to opioids. Misuse and abuse is of particular concern if opioids are prescribed for chronic pain. Opioids that are full mu-receptor agonists may have a greater abuse potential (eg morphine, oxycodone) and may not be suitable for patients identified to be at risk of opioid misuse; however, choice of opioid is only one mitigating strategy for people identified at risk, see Opioid misuse, abuse and diversion.

Start an opioid trial with a low dose. If response to the initial dose is inadequate, increase the dose slowly—the risk of opioid-related harm increases with higher doses, older age and concomitant use of sedative drugs.

Note: When using an opioid for chronic noncancer pain, ‘start low and go slow’.

In adults younger than 70 years, initiate an opioid trial with a modified-release opioid formulation. A low dose of an immediate-release oral opioid may be used initially in frail older patients to gauge analgesic response and enable cautious dose titration. If tolerated, and ongoing opioid analgesia is required, change to a modified-release formulation; see Equianalgesic doses of opioids.

Advise the patient not to use the opioid to manage breakthrough pain or flares of chronic noncancer pain (ie exacerbations of chronic pain unrelated to a new injury or condition). For patient information explaining the role of opioids in chronic noncancer pain, see [URL].

If a trial of buprenorphine is appropriate for adults with chronic noncancer pain, use:

buprenorphine 5 micrograms/hour transdermally, replaced every 7 days. Titrate the dose by 5 micrograms/hour increments no more frequently than every 7 days until adequate analgesic effect is achieved or a dose of 20 micrograms/hour is reached. Do not use more than 20 micrograms/hour without specialist support. Older patients require lower doses and slower titration. chronic noncancer pain buprenorphine buprenorphine buprenorphine

If a trial of morphine is appropriate for adults with chronic noncancer pain, use²:

1 morphine (12-hour) modified-release 5 to 10 mg orally, once or twice daily. Increase by 5 to 10 mg every 3 days until adequate analgesic effect is achieved. Do not use more than 40 mg daily without specialist support. Older patients require lower doses and slower titration. chronic noncancer pain morphine morphine morphine

1morphine (24-hour) modified-release 10 to 20 mg orally, daily. Increase the dose by 10 mg every 3 days until adequate analgesic effect is achieved. Do not use more than 40 mg daily without specialist support. Older patients require lower doses and slower titration. morphine morphine morphine

If a trial of oxycodone is appropriate for adults with chronic noncancer pain, use³:

oxycodone modified-release 5 mg orally, once or twice daily. Increase by 5 mg every 3 days until adequate analgesic effect is achieved. Do not use more than 30 mg daily without specialist support. Older patients require lower doses and slower titration. chronic noncancer pain oxycodone

If a trial of tapentadol is appropriate for adults with chronic noncancer pain, use⁴:

tapentadol modified-release 50 mg orally, once or twice daily. Increase by 50 mg every 3 days until adequate analgesic effect is achieved. Do not use more than 300 mg daily without specialist support. Use lower doses and slower titration strategies in older patients. chronic noncancer pain tapentadol

If a trial of tramadol is appropriate for adults with chronic noncancer pain, use:

tramadol modified-release 50 mg orally, once or twice daily. Increase by 50 mg every 3 days until adequate analgesic effect is achieved. Do not use more than 400 mg daily without specialist support. Use lower doses and slower titration strategies in older patients. chronic noncancer pain tramadol

Review the patient 1 week after starting an opioid trial or following a dose change. If the patient is not tolerating the opioid, consider a dose reduction or switching to another opioid. If the patient is stable (eg tolerating therapy, low risk of aberrant behaviour, improved pain relief), review after 2 weeks, then every 4 weeks. If there is risk of aberrant behaviours (eg unsanctioned medication use, diversion by the patient), more frequent monitoring may be required; consider take-home naloxone for patients at risk of overdose.

Analgesic efficacy should be apparent after a 4 week opioid trial. If the opioid trial is unsuccessful, reconsider the diagnosis because the pain may not be opioid responsive. Seek specialist advice for additional management strategies⁵ and consider deprescribing the opioid. Changing to another opioid will not improve treatment efficacy.

Note: If an opioid trial is unsuccessful, changing to another opioid will not improve treatment efficacy for chronic noncancer pain.

If an opioid trial is effective, limit opioid use to the shortest duration of therapy that enables the patient to establish self-management strategies. Even if effective, opioids should not be prescribed for longer than 12 weeks, unless under specialist advice.

Note: Opioids should not be prescribed for longer than 12 weeks, unless under specialist advice.

¹ Specialist advice (eg paediatrician, specialist pain medicine physician) can be sought via phone or email; patients do not necessarily require referral to a specialist.Return

² Modified-release morphine is available in both 12-hour and 24-hour formulations; ensure the formulation is included on the prescription to reduce the risk of error.Return

³ At the time of writing, modified-release oxycodone 5mg tablets are only available on the Pharmaceutical Benefits Scheme (PBS) in combination with naloxone (ie oxycodone + naloxone 5mg/2.5mg tablets). See the PBS website for current information.Return

⁴ Modified-release tapentadol tablets are not available in a lower strength; this dose is approximately twice the equianalgesic dose of other initial doses stated.Return

⁵ Specialist advice can be sought via phone or email; patients do not necessarily require referral to a specialist pain medicine physician.Return