Commencing Strong Opioids

Decision to commence strong opioid trial:

  • The opioid trial establishes whether the patient achieves any reduction in pain with the use of opioids. The patient and prescriber should agree some readily assessable outcomes that indicate opioids may play a role in the patient’s management e.g. Aim for 30-50% improvement in pain and / or significant improvement in functional ability or if pain affects sleep, sleep improvement could be an outcome.
  • If there is no useful pain relief within 2-4 weeks then any long term benefit is unlikely; and the opioid should be tapered and stopped within one week. For intermittent pain allow for two or three episodes of flare ups. A successful short-term opioid trial does not predict long-term efficacy.
  • STOP weak opioid and care with polypharmacy. There is the potential for cumulative central nervous system depressant effects of e.g. drowsiness, respiratory depression if prescribed with other central nervous system depressants such as pregabalin and gabapentin (Advice for prescribers on the risk of the misuse of pregabalin and gabapentin).
  • Do not offer opioids for managing chronic low back pain (NICE NG 59) or with pain typical of fibromyalgia.
  • Document relevant clinical findings that support the decision to prescribe opioids + information given to patient e.g. DVLA


Long term prescribing of strong opioid:

  • First line strong opioid: Oral morphine (Zomorph®) modified release. Other opioids second line, see guidance - Fentanyl TD Guidance, Buprenorphine TD Guidance, Oxycodone Guidance
  • Agree goals of therapy – keep dose low and intermittent. Consider use of ‘Opioid prescription agreement
  • Discuss and document exit strategy; and circumstances under which opioid therapy should be discontinued. Set ground rules for lost scripts or early requests for script. Avoid repeat prescribing. Keep under regular review (at least 6 monthly) – preferably one prescriber to manage reviews and prescriptions (28 day prescription)

**Any dose increase should not exceed 50% previous dose** Do not increase above oral morphine 120mg /day as risk of harm increases substantially with no increased benefit

(approx. equivalent to oxycodone 60mg/day, fentanyl 37mcg/hr patch, Buprenorphine 52.5mcg/hr patch)