Best practice guidelines recommend that patients prescribed long-term opioids for persistent pain should be reviewed at least 6-monthly. Particular considerations when reviewing the continued effectiveness of opioids are any changes in the patients underlying condition or other treatment (for example if they have had joint replacement surgery), the continued effectiveness of opioids, the presence / frequency of troublesome side-effects and any concerns about problematic use (Opioids Aware).
The 4 A’s can be a a useful way to remember the different areas to consider when reviewing opioids
- Do opioids provide continued pain relief?
- Have opioids increased activity levels and /or led to resulted in functional improvement?
- Adverse effects
- Do opioids cause any unwanted or troublesome side-effects?
- Aberrant behaviour
- Does the patient take their opioids as prescribed? Are there concerns about problematic opioid use or opioid misuse?
Take a few minutes to watch the following video clip of a GP talking to a patient about opioid. What do you think is done well here? What might you want to do differently? Consider how likely it is that the patient may feel motivated to make a change to their opioids following this conversation ?
Patients often have strong opinions about their opioids and many assume pain will be worse if opioids are reduced or stopped. It’s not surprising therefore that discussions about opioids may encounter defensiveness. Jumping in too soon with judgments and advice can lead to some patients digging their heels in and becoming more resistant to change. In the following presentation we’ll look at taking a slightly different approach , that can still allow for a comprehensive review of opioids effects in line with the 4 A’s.
Useful questions to tap into patient concerns about reducing opioids
Fear of worse pain and /or withdrawal symptoms are important potential barriers to reducing opioids and quite commonly fueled by previous experience of stopping or reducing opioids suddenly. This may have been deliberate, for example because the patient was fed up of taking lots of medicines and still being in pain, but often it’s accidental, for example because they forgot to request their repeat prescription or stayed away from home longer than expected without an adequate supply of their opioids. Whatever the reason, finding out about patients’ previous experience of reducing or stopping opioids is very important way of tapping into any concerns they may have about reducing opioids. Previous experience of withdrawal symptoms can also leave patients believing that they are addicted to their opioids and that it will inevitably be very hard to come off them.
One very useful question you should ask all patients
” Have you ever tried stopping or reducing your [name of opioid] before?”
& if they have, you can follow up with
“What happened? Did you stop suddenly? / How quickly did you reduce?”
“What did you notice? How did you feel?”
The Talking about Opioids lesson later in this module will give you some ideas about how to address some of the common concerns that may come to light.