Severe chronic pain following spinal cord damage: a pragmatic perspective for prescribing opioids

The controversial issue of prescribing opioids to people with spinal cord damage who have severe pain is discussed in this paper. The reasons for concern regarding the increase in opioid prescription over recent years are outlined, along with a summary of the major potential adverse outcomes associated with opioids, such as falls, respiratory suppression, adverse endocrine effects, cognitive impairment, and the potential for opioid abuse, addiction and death. Situations when opioids are more appropriate are considered to be in the immediate post-trauma or post-operative periods. More controversial is the use of opioids in chronic non-cancer pain. A brief review of the evidence regarding opioids in chronic non-cancer pain is presented, and strategies outlined for reducing the risk of adverse consequences from opioid use in chronic non-cancer pain. These strategies include considerations before starting opioids, during initiation, monitoring activities and the cessation process. A vital consideration before starting opioids includes ensuring that all alternatives to opioids have been fully considered and trialled. Finally, some pragmatic proposals for prescribing opioids in people with SCD are suggested. It is recommended that before opioids are commenced, that the informed consent process should be complimented by a treatment agreement, with an initial 4-week trial period, and close monitoring of established goals.