Which opioid to choose

Depending on the pain mechanism and patient co-morbidities, this can include acetaminophen, nonsteroidal anti-inflammatory drugs NSAIDs , serotonin and norepinephrine reuptake inhibitors SNRIs , tricyclics and gabapentinoids.

An opioid trial should be guided by clear criteria for monitoring the success of an opioid trial and a plan for stopping opioids if criteria are not met. Prolonged use of opioid analgesia beyond the immediate postoperative period or other acute pain episode is not recommended. Opioid use poses considerable health risks to patients including opioid use disorder, overdose, and side-effects such as psychomotor impairment.

While opioid analgesia may be appropriate in select circumstances, prolonged use of opioids beyond the immediate postoperative period and for chronic non-cancer pain is not recommended.

Instead, clinicians and patients should consider alternative therapies, such as non-opioid pharmacologic therapy or non-pharmacologic therapies. If opioid analgesia is required, the lowest effective dose, potency, and number of doses required to address the acute pain episode should be prescribed.

General Surgery recommendation 7. Non-steroidal anti-inflammatory drugs and triptans are recommended first line treatments for acute migraine therapy. Opioids may produce increased sensitivity to pain and increase the risk that intermittent headache attacks will become more frequent and escalate to a chronic daily headache syndrome medication overuse headache , particularly when opioids are used on 10 days a month or more.

Opioids may impair alertness and produce dependence or addiction syndromes. Headache Recommendation 2. If this is not sufficient for managing pain then an opioid may be considered. If an opioid analgesic is appropriate consider limiting the number of tablets dispensed. Hospital Dentistry Recommendation 1. Evidence shows that opioids are not more effective than other analgesics for certain chronic pain conditions.

Furthermore, evidence is mounting that the risks of opioid treatment, including opioid use disorder, overdose, and other previously under-recognized side effects e. Thorough patient-centred discussion about risks, benefits, and expectations is essential.

Hospital Pharmacy Recommendation 6. While opioids may be used to manage abdominal pain in select acute settings in IBD patients, their prolonged use may mask the symptoms of active IBD or its complications e. Chronic opioid use has been proven ineffective for non-malignancy associated chronic pain and is associated with excess mortality. Moreover, because of their potential risk for dependence, their long-term use for managing IBD-related abdominal pain should be avoided especially in the context of the opioid crisis in North America.

Inflammatory Bowel Disease Recommendation 2. Several non-opioid therapies including both drug and non-drug alternatives may achieve a similar magnitude of improvement in pain and function more safely without the potentially serious side effects of opioid therapy e. Internal Medicine Recommendation 6. Opioids and cannabinoids have weak or inconclusive evidence in effective treatment of neuropathic pain. The well documented risks of opioid and cannabinoids include nausea, sleepiness, impairment, dependence, and development of substance use disorders.

With impairment comes further risks to oneself and others in altered judgement in the workplace or while operating a vehicle. Opioids come with an additional risk of decreased respiratory drive and fatality with overdose.

Neuropathic pain can be treated effectively using agents with demonstrated efficacy and significantly less risks compared to opioids and cannabinoids. Neurology Recommendation 3. Opioids are not adequate for pain control for patients with migraines. The risk for harm, including impairment, dependence, tolerance, medication overuse headaches, and opioid use disorder with opioids is greater than the documented benefit.

Additionally, opioids may worsen nausea and vomiting associated with the migraine. Prescription opioids for migraines would have minimal to no benefit with the excess of risk, and contribute to the opioid crisis. Neurology Recommendation 6.

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Register for free. FutureLearn offers courses in many different subjects such as. Pain ratings of 7 to 10 mark severe pain. However , many patients use these numbers differently. The Three-Step Analgesic Ladder of the World Health Organization uses these three categories of pain to guide analgesic drug therapy see figure 1. Patients receiving no analgesic therapy, who have mild-to-moderate pain should be treated first with nonopioid analgesic drugs Step 1.

If a patient has mild-to-moderate pain despite taking a nonopioid analgesic, the dose of the nonopioid analgesic should be maximized and a step 2 opioid analgesic a "mild" opioid such as codeine, hydrocodone or oxycodone should be added. Patients who have moderate-to-severe pain or pain unrelieved by maximal therapy with Step 2 opioids require a change to a Step 3 opioid a "major" opioid such as morphine, hydromorphone or fentanyl.

Patients with mild-to-moderate pain should be treated first with nonopioid analgesic drugs Step 1. Patients who have moderate-to-severe pain or pain unrelieved by maximal therapy with Step 2 opioids require a change to a Step 3 opioid a "major" opioid such as morphine, hydromorphone, oxycodone or fentanyl. Patients typically have tried these agents for pain relief before seeking assistance from their physician. All of these agents have a ceiling effect in analgesia a maximum dose beyond which analgesic effect does not increase , and all have potential for serious adverse effects.

They also all have an anti-pyretic effect and do not cause withdrawal symptoms. Acetaminophen is a useful analgesic whose mechanism of action is poorly understood inhibition of a COX-3 enzyme has been proposed.

Excessive doses can cause serious, even fatal, hepatic injury, and the incidence of such injury has been rising steeply in recent years. The maximum safe dose for chronic administration is currently considered to be grams per day.

Many experts recommend a maximum chronic dose of 3 grams, or even less, for elderly patients and those with hepatic impairment. Acetaminophen does not have any significant anti-inflammatory action or any effect on platelet function.

Use of alcohol with acetaminophen is a significant risk factor for hepatic injury — patients taking maximal doses of acetaminophen should be cautioned to avoid alcohol.

An important although under-recognized interaction with warfarin is an additional concern with use of acetaminophen. NSAIDs including aspirin may also be useful analgesics. They work by inhibiting cyclooxygenase COX , the enzyme that converts arachidonic acid to prostaglandins.

In addition to this peripheral effect, data suggests that NSAIDs also work at central action in the brain and spinal cord. The frequency and potential seriousness of these effects is often under-estimated.

These reactions can range from simple vasomotor rhinitis all the way to anaphylaxis. Cross-reactivity is common, so patients who have had hypersensitivity reactions to one NSAID most commonly aspirin have a relative contraindication to trials of others. Opioid Analgesics [back to top]. General In Sydenham said: "Among the remedies which it has pleased Almighty God to give to man to relieve his sufferings, none is so universal and so efficacious as opium," and this is still true hundreds of years later.

Most of the opioids with the exceptions of methadone and fentanyl have similar first order pharmacokinetics. Plasma concentrations are achieved rapidly:. Initial effects minutes. Peak plasma concentration minutes. Fentanyl reaches full effect sooner than any other opioid because of its highly lipophilic nature. Most also have pharmacologically active metabolites that are renally cleared but have longer half-lives than the medication itself. These metabolites vary in clinical significance.

The neurotoxic active metabolite of meperidine was described first, but further work has made it clear that both morphine and hydromorphone also have active metabolites with CNS toxicity. Case reports suggest that this will probably uncovered for fentanyl and methadone as well although the clinical impact is typically less.

There is no clear evidence about which is the best opioid for patients with marked renal impairment, but many experts recommend methadone and fentanyl as the ones least likely to accumulate in a patient with renal impairment.

In addition, they need access to "p. Few patients have pain that is completely stable and steady; most experience exacerbations that require additional breakthrough dosing at least occasionally. Regular dosing : The usual intervals for effective regular dosing for specific opioids are included in the Equianalgesic Table. Simply divide the 24 hour total dose by the dosing method of the sustained release medication usually q 12 hours to calculate the new regimen.

One to one-and-one-half hours is a quite conservative interval for repeat oral dosing for continued pain; and minutes is a similarly conservative interval for repeated intravenous dosing. In the case of severe pain, clinical judgment should be used to shorten the intervals for repeat dosing, and the dose itself should be aggressively increased.

In many cases, an ongoing need for dosing at short intervals suggests a need for dose increase. See Equianalgesic Table. Doses are limited only by side effects. For mild or moderate pain, twenty four hour intervals are often adequate for reassessment and titration.

The dose adjustments can be relatively conservative. For moderate pain, more rapid titration is often appropriate, and severe pain should be regarded as a medical emergency.