NHS Wales has seen a significant increase in use of strong opiates (11%) as well as gabapentin and pregabalin (16%) in the year 2015-2016 4.
Medicines frequently used in the treatment of chronic pain like tramadol, gabapentin, pregabalin and morphine can cause problems of tolerance, dependence and addiction. There have also been deaths related to use of these medications so they should not be prescribed lightly. More so, they are not very effective at treating chronic pain and the risks of long-term use of opiates, in particular their effects on the endocrine and immune system, must be carefully considered before prescribing.
80 per cent of people taking opiates will have an adverse reaction.
People should be advised not to drive when strong opiate treatment is started and doses are increased. It is their responsibility to inform the Driving and Vehicle Licensing Agency. Injectable formulations should not be used and fentanyl and buprenorphine patches can be difficult to titrate and should be avoided. People taking the equivalent of 120mg of oral morphine within 24 hours with no benefit should be referred to a specialist for advice.
National prescribing indicators are evidence-based means of comparing different ways in which medicines are prescribed and allow current practice to be compared with an agreed quality standard. Tramadol, gabapentin, pregabalin and morphine will be monitored in 2016-20175.
Some people will need secondary or tertiary care input for management of chronic pain, however, the majority of people will be managed in primary care6. When prescribing analgesics, it should be remembered that there may be differences in effectiveness and tolerance between patients, so prescribers should initiate medicines at lower doses and titrate slowly according to individual response.
A full history and examination should be undertaken paying particular attention to “red flag” symptoms and signs prior to commencing long term medication. Investigations can be ordered but be mindful that findings can be unrelated to the pain. The pain ladder (created by the World Health Organisation) was not devised for ongoing pain and a more pragmatic approach may need to be adopted.