Recommendations for Chronic Opioid Therapy (COT) in Specific Pain Syndromes
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.
Osteoarthritis, rheumatoid arthritis and ankylosing spondylitis
Non-cancer spinal pain
Non-cancer spinal pain (i.e. cervical, thoracic, lumbar, and/or lumbosacral), with or without neurological involvement, is extremely common throughout the world and will affect most people at some stage of their lives. The causes are protean. Most patients with one or more of these painful disorders can be treated successfully with standard multimodal methods, some of which are described on the South African Spine Society website (http://www.saspine.org). Many of the painful episodes are of relatively short duration and are self-limiting. Paracetamol, non-steroidal anti-inflammatory drugs (NSAIDs), amitriptyline, and muscle relaxants usually provide adequate pain relief. In a minority of cases, SR tramadol might be necessary in the short term. On only rare occasions, parenteral opioids may be necessary for short periods.
A small percentage of patients develop or present with chronic non-cancer spinal pain that is resistant to standard treatment programmes, or in whom standard treatment programmes are inappropriate. The causes of such chronic pain may include multiple-level degenerative spinal disease (especially in the elderly), so-called ‘failed spinal surgery’, undiagnosed structural pathology, or chronic nonspecific spinal pain. These patients should be carefully re-evaluated for missed pathology, inadequate treatment, treatment non-compliance, secondary gain motives and psychosocial factors. A trial of opioids for pain amelioration can be contemplated in such patients, preferably in consultation with a pain clinician. The trial of opioids must be in addition to other concomitant treatment modalities, including simple analgesics, appropriate physical activity, physical therapy, ergonomic advice, and psychological guidance when necessary. Patients should be counselled extensively about the possible failure of opioid therapy, potential side-effects, the fact that the pain will not be relieved completely, and that it will be necessary to continue with all the other modalities of treatment.
A trial of opioids should be in accordance with this guideline.
Osteoarthritis, rheumatoid arthritis and ankylosing spondylitis
Tramadol is recommended for initial management of pain associated with osteoarthritis of the hip or knee. Opioid analgesics are strongly recommended for patients with symptomatic arthritis who do not achieve an adequate response with either non-pharmacological or pharmacological modalities and who are either unwilling to undergo, or who are not candidates for total joint arthroplasty.[7]
In patients with ankylosing spondylitis, analgesics such as opioids might be considered for pain control in patients in whom NSAIDs are ineffective, contraindicated and/or poorly tolerated.[8]
Patients with rheumatoid arthritis (RA) report pain relief as a high priority and opioid analgesics are often prescribed, but existing RA treatment guidelines provide little direction in this regard. There is a paucity of high-quality evidence for treating RA pain with SR strong oral opioids such as morphine or oxycodone, or transdermal preparations such as fentanyl. There are also no adequate data for oxymorphone, hydromorphone or buprenorphine. Since RA is a chronic disease, analgesic medications may be required in both the short term and long term, e.g. during flares of inflammatory activity or while waiting for disease-modifying antirheumatic drugs (DMARDs) to take effect (short term), or with irreversible joint damage or the development of secondary pain syndromes (long term).[9]
Fibromyalgia
Treatment recommendations for widespread soft-tissue pain, including fibromyalgia, suggest that tramadol may be useful for managing this type of pain. There is currently no evidence to recommend long-term use of strong opioids in patients with fibromyalgia. Long-term use of strong opioids in patients with fibromyalgia has been associated with the development of opioid-induced hyperalgesia.[10]
Chronic pelvic pain
There is currently no evidence that long-term opioids are effective in the treatment of chronic pelvic and abdominal pain of uncertain aetiology. The safety of opioid use in these conditions has not been determined and chronic opioid therapy (COT) is therefore not recommended.
The long-term management of patients with conditions such as interstitial cystitis/painful bladder syndrome, chronic prostate pain, and irritable bowel syndrome should be facilitated by practitioners with special expertise/interest in these conditions and is best conducted in a multidisciplinary setting.
Neuropathic pain
Strong opioids can be successfully used for managing neuropathic pain, either as third-line therapy, or as an intermittent adjunct to first- and second-line recommended medications (e.g. pregabalin, gabapentin, and antidepressants).[11] The use of long-term COT for neuropathic pain remains a contentious issue as there are almost no studies where opioids have been continued for longer than six months. Patients who are considered for COT should be carefully selected and they should improve clinically with an initial trial of therapy, as described earlier in this document.