Optimising non-opioid medicines

Although willing to consider reducing ineffective opioids, patients often expect to be offered an alternative medicine for their pain and it makes sense to review the effects of their current non-opioid pain medicines whilst reviewing opioids.

Reviewing non-opioid pain medicines alongside opioids provides an opportunity to:

However, for the majority of patients with persistent pain, it is unlikely that there will be a safe and effective alternative non-opioid analgesic you can offer.

Principles of prescribing for persistent pain

Key considerations regarding the use of non-opioid analgesics for persistent pain are summarised below with links to relevant NICE Guidance.

*NICE CG177 Osteoarthritis: care and management **NICE CG 173: Neuropathic Pain in Adults
*NICE CG177 Osteoarthritis: care and management, NICE Guideline 59: LBP & Sciatica over-16’s
*NICE CG 173: Neuropathic Pain in Adults **NICE draft guideline: Chronic Pain in over-16’s: Assessment & Management
* Friedman 2017 ** NICE Guideline 59: LBP & Sciatica in over-16’s.
***NICE draft guideline: Chronic pain in over 16s: assessment and management
NICE Guideline 144 Cannabis-based medicinal products

Deprescribing non-opioid pain medicines

Patients with persistent pain often take a number medicines for pain, which may also be ineffective and /or potentially harmful. Of particular concern is co-prescribing of other potentially sedating medicines such as gabapentinoids, benzodiazepines, Z-drugs for pain and/or mood/ sleep. This increases the risk of opioid-related harm considerably and increases the likelihood of opioid misuse.

It is recommended that only one change to pain medication is made at a time. The first priority of PROMPPT is opioid tapering, in patients who agree to this, and changes to non-opioid medicines can be added to the plan at a later stage.

Where patients are not ready/ willing to reduce opioids, or where this does not seem necessary (i.e. low dose, functional benefits outweighing any adverse effects/ risk) then deprescribing of other ineffective/ potential harmful pain medicines can be considered at an earlier stage.

As for opioids, gradual reduction (tapering) is recommended when deprescribing gabapentinoids (see below), benzodiazepines & Z drugs (see NICE approved BZRA Deprescribing Algorithm 2019 ) and antidepressants (see NICE Guideline on Depression in Adults).  

In addition to reducing the risk of withdrawal symptoms, gradual reduction of any potentially ineffective pain medicines also allows for any previously unnoticed benefits to emerge and offers the opportunity to continue at the lowest effective dose, if it transpires that there is some benefit.

Deprescribing gabapentinoids