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Where now for opioids in chronic pain?
  1. Cathy Stannard Dr
  1. Consultant in Complex Pain and Pain Transformation Programme Clinical Lead, NHS Gloucestershire CCG, Sanger House, 5220 Valiant Court, Gloucester Business Park, Brockworth, GL3 4FE
  1. Correspondence to Dr Cathy Stannard, cfstannard{at}

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Key learning points

  • Opioids are valuable in the management of acute pain, pain related to cancer and for pain management at the end of life.

  • There is a lack of robust evidence on the benefit of long-term opioids in the management of chronic pain.

  • Inappropriate use of long-term opioids in chronic pain is associated with serious adverse effects.

  • The risk of harm from opioids increases significantly above a dose equivalent to 120 mg/day of oral morphine.

  • In conjunction with the patient, regularly review the effect of opioid treatment and consider whether there is a need to reduce the dose or stop the opioid.


Chronic pain has always been and will remain difficult to manage. There have been important developments in our understanding of the neurobiology of pain, but perhaps the greatest advance is our ability to analyse trial data more critically and to realise that we may have been wrongly optimistic about the use of some therapies. Although the publication of high-quality literature reviews may have reduced our therapeutic options, it also provides an opportunity to improve patient care by ensuring that we are not exposing patients with pain, whose lives are difficult enough as it is, to the harms of medicines that do not help them.

In particular, there is a need to reconsider the place of opioids in the management of chronic pain. This includes the so-called weak opioids (eg, codeine and dihydrocodeine), and strong opioids (eg, morphine, oxycodone, fentanyl and buprenorphine), as well as tramadol (a non-selective agonist at mu, delta and kappa opioid receptors with monoaminergic properties), which should be considered alongside the strong opioids.

Opioids emerged into the chronic pain management scene in the 1990s. The recognition of their potent role in the management of acute and end-of-life pain, the inappropriate adoption of WHO analgesic ladder designed for …

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