- You’re probably not going to get the patient to a pain-free state. Be realistic and upfront about expectations, and aim for pain reduction to a manageable level, rather than elimination of pain.
- Tramadol works mainly through noradrenergic and serotonin pathways, with only about 20% of its activity being at opioid receptors. Or, in plain English, it’s worth trying where codeine’s failed. It also has considerably less potential for abuse. However, it can lower seizure threshold (avoid if history of epilepsy) and interacts with TCAs or MAOIs.
- Tapentadol works on both noradrenergic and opioid receptors but not on serotonin. I suppose that might be useful for patients who get serotonin-related SEs with Tramadol.
- Long-term opioid use can cause hormone dysfunction, immunosuppression, and worsening of some types of pain. However, it is still an advisable option to consider for chronic noncancer pain.
- Sustained-release opioids are less likely to lead to addiction.
British Pain society recommendations for opiate use in chronic noncancer pain:
- Establish a treatment plan, with goals
- Review patients regularly for side-effects, sleep or mood changes, or signs of abuse
- Aim for analgesia rather than sedation/anxiolysis
- Patients with psychological co-morbidity or alcohol problems can still use opioids, but should be managed by the Pain Clinic or other specialists
- Avoid injectable opioids
- If tolerance appears to be developing, refer to either Pain Clinic or addiction services
(Prescriber 5th Sept 2012; 23(17))