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Practical aspects of prescribing 

Practical aspects of prescribing
Chapter:
Practical aspects of prescribing
Author(s):

Cathy Stannard

, Michael Coupe

, and Anthony Pickering

DOI:
10.1093/med/9780199678075.003.0013
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date: 21 October 2019

There is no right or wrong type of patient suitable for opioid therapy. Opioids may play a partial role in the management of both nociceptive and neuropathic pain. The benefits and adverse effects of opioid treatment should be discussed with the patient and relevant others, and aims of therapy agreed and documented. Patients should undergo a trial of opioid therapy, with reasonable dose adjustment, active management of side effects, and monitoring of adverse effects and goals of treatment. There should be agreement between the prescriber and patient to stop opioid therapy if aims of treatment are not fulfilled within two or three dose adjustments. Harms of opioids are dose-related, and, in most circumstances, doses should not exceed 120 mg morphine equivalent per 24 hours. For most persistent pain conditions that are suitable for opioid therapy, sustained-release rather than immediate-release formulations are preferable. Clear allocation of responsibility for prescribing opioids in the long term should be agreed, including a plan for regular review of the patient to assess continuing utility of the opioid drug. Patients who fail to respond to one opioid drug may show a more favourable response with an alternative opioid. Tables describing relative potencies of opioids should serve as a guide only when switching a patient from one opioid to another. Caution should be exercised when switching a patient to or from methadone. The role of intrathecal opioid therapy in the management of persisting non-cancer pain needs further clarification.

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