Home' Australian Pharmacist : Australian Pharmacist June 2016 Contents Australian Pharmacist June 2016 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
Opioid interference with sleep
architecture leads to poor quality sleep
and this has been associated with
increased pain sensitivity.
based study in 2007–8 showed that both
the frequency and severity of insomnia,
in addition to sleep onset latency and
sleep efficiency, were associated with
pain sensitivity in a dose–response
Opioid use is associated with blunted
mood and increased rates of depression,
which increase the perception of pain
Another complex effect of opioids is
opioid-induced hyperalgesia (OIH). This
effect is a paradoxical amplification of
pain associated with allodynia (a painful
response to a non-painful stimulus) and
hyperalgesia (an increased response
to a normally painful stimulus).
mechanism of effect is not clearly
understood but one suggestion is that
opioids activate glial cells in the central
nervous system and these in turn
contribute to neuronal sensitisation
4,9 OIH may occur at
a different location to the currently
treated pain or it can be widespread and
the onset may be abrupt or gradual.
Increasing the dose of the opioid
will cause worsening of the pain and
decreasing the opioid dose is likely to
relieve the pain.
It is conceivable to
think that Mrs PM’s pain may be due to
OIH and reduction in dose of opioid may
offer benefit for her.
Table 1 lists the adverse effects
associated with long-term use of
opioids. Of significant concern for
Mrs PM is the potential for respiratory
depression. Such an effect increases
the risk of death – especially when
combined with benzodiazepines.
Benzodiazepines are the most common
drug associated with codeine-related
deaths in Australia.
A 2014 report stated that opioid-related
hospitalisations in Australia more than
doubled from 1998–2009 and has
outnumbered hospitalisations due to
heroin poisonings since 2001.
deaths due to accidental poisoning
(from pharmaceutical opioids and illicit
substances combined) increased from
151 to 266 from 2002–2011.
How much opioid is too much?
Australian (and most international)
guidelines recommend that a pain
specialist be involved where a person
takes the equivalent of 90–100 mg of
morphine daily – or more.
definitely be suggested to the GP to
consider urgent referral for Mrs PM, but
also to consider dose reduction of the
opioid due to its seeming lack of effect,
the possibility of OIH and the significant
risk for respiratory depression with the
high dose of benzodiazepines.
If the doctor/specialist decides to
reduce the opioid dose, there needs
to be a gradual reduction in dose.
Unfortunately, there is no evidence-
based rate for tapering in such situations
– reductions of 5–10% to 20–50% of
the dose per week are discussed in
During the weaning-off
period, regular monitoring is required
as well as additional support such as
physical therapies and counselling.
The patient’s mental state should
also be regularly reviewed as opioid
withdrawal can be associated with
The original questions posed for this
HMR were: is the use of an opioid
warranted and is the dose acceptable?
Clearly the evidence behind long-term
use of opioids in non-cancer pain is
weak (and the potential adverse effects
are significant) but some people do
Perhaps Mrs PM was originally
a responder, so the original use of an
opioid may have been warranted. But
her dose is undeniably excessive now
and needs review.
Table 2. Online information
The Chronic pain communication tool is a free tool that helps
patients talk about their chronic pain with their doctor,
specialist and/or allied health professional.
It provides them with:
• a better picture of their chronic pain
• a printout or PDF with all the issues they want to talk
• access to chronic pain information, resources and tools
At: http://painhealth.csse .uwa.
This shows patients how to gradually, safely and effectively
increase their daily level of activity
Helps patients understand chronic pain better and
reinforces the importance of them being actively involved
in management of the pain
Amongst other information, there are testimonial videos of
‘real’ people and their journey with chronic pain
* BEACH: Bettering the Evaluation and Care of Health. This program continuously collects information about
the clinical activities in general practice in Australia. As of July 2015, it had analysed 1,700,000 GP–patient
"ANNUAL DEATHS DUE TO
ACCIDENTAL POISONING (FROM
AND ILLICIT SUBSTANCES
COMBINED) INCREASED FROM
151 TO 266 FROM 2002–2011."
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