Abstract
Thank you for taking the time to consider the challenges surrounding opioid use and prescribing outlined in the first edition of the British Journal of Pain.
Opioids may be of benefit for a relatively small proportion of patients with pain from non-cancer diagnoses, providing pain relief that supports engagement with physical rehabilitation and improves psychological and social functioning. You rightly highlight the importance of improvements in functional parameters and ask the important question as to how these might be measured.
Whilst there is increasing consensus on the domains that should be included in clinical trials, such as IMMPACT, adoption of all of these may be neither feasible nor practical in everyday clinical practice. Evidence is not available to suggest that a patient who scores above a certain arbitrary threshold using measures, such as the SF-36, will have a worse outcome with opioid therapy or that this is more likely to be associated with problem drug use.
Patients whom we see in clinic are heterogeneous and diverse in their needs. Before considering prescribing opioids, the prescriber should give the patient realistic expectations that opioid therapy is unlikely to take away their pain completely. It is more important to agree realistic patient-specific goals for opioid therapy and to ensure that these are reviewed at each consultation to assess that they have been met or that progress has been made towards them. This provides the basis for an objective, patient-focused assessment of functional improvement. Where there has been little or no progress in relation to these agreed outcomes, this should prompt a review of the decision to continue the opioid prescription. As specialists based predominantly in secondary care, we need to communicate our prescribing plans with colleagues in primary care so that all who prescribe are aware of the importance of using opioids to support improvement in patient function.