Introduction, Objectives & Methods
This guideline is endorsed by the following professional groups: Cape Pelvic Pain Society, PainSA, South African Rheumatism and Arthritis Association, and South African Society of Anaesthesiologists.
Introduction
Chronic pain is common, affecting around one in five patients in primary care. It may occur even more frequently in older individuals, whose presentation is often complicated by age-related physiological changes, comorbidities and multiple medications. Chronic pain patients are more likely to report anxiety or depression and significant activity limitations and often have unfavourable perceptions of their health.[1] Chronic pain may have a significant impact on health-related quality of life and may be difficult to manage.
Opioids are well accepted for the treatment of severe acute pain and chronic pain associated with cancer and at the end of life. Although there are short-term studies demonstrating efficacy in chronic non-cancer pain (CNCP), less is known about their efficacy and safety with long-term use. The potential for addiction, tolerance and dependence associated with this class of analgesics also remains a concern.
Nevertheless, opioids are increasingly being used to treat persistent pain. Limited evidence indicates that they can be effective therapy for a carefully selected group of patients as part of a wider management plan focused on reducing disability and improving quality of life. However, appropriate patient selection is paramount, requiring a comprehensive physical and biopsychosocial assessment to establish the diagnosis and to guide management decisions.
This guideline was developed by a multidisciplinary panel of clinicians who treat patients with chronic pain to provide recommendations for patient selection and the use of opioids for CNCP.
Objectives
To provide a brief and practical guideline for the use of chronic opioid therapy (COT) in patients with CNCP. The target audience is all clinicians in primary and specialty settings who provide care for adults suffering from CNCP. The management of acute pain, postsurgical pain, labour pain, cancer pain, pain at the end of life, and CNCP in children is not addressed in this guideline.
This is a guideline only and is not intended to constitute inflexible treatment recommendations or to represent the standard of care. The recommendations here may not apply to all patients or all clinical situations and shared decision making among a multidisciplinary treatment team is encouraged.
Methods
International guidelines, reviews and recommendations for the use of opioids in patients with CNCP were identified through a literature search and reviewed by the panel. A consensus guideline for South Africa (SA) was developed from these publications and the clinical experience of the physicians on the panel. As a basis for the document, four international guidelines were specifically chosen. These were recommendations from the British Pain Society (2010), the American Pain Society – American Academy of Pain Medicine Opioids Guidelines Panel (2009), the Canadian National Opioid Use Guideline Group (2010) and the American Society of Interventional Pain Physicians (2012).[2-5]