Opioid prescribing: Balancing overconsumption and undersupply.

Opioids continue to be a topic of much discussion and controversy. At a packed special session at the World Congress on Pain to discuss the role of opioids in pain medicine, the speakers aimed ambitiously to find a path between undersupply in many developing countries and overconsumption elsewhere, particularly in the United States and Canada. Global consumption of opioids has increased at an alarming rate over recent decades. While the number of people in the United States accounts for only 5% of the world’s population, 80% of opioid consumption occurs there. There are many developing countries that struggle, as a result of unwieldy regulation and legislation, to obtain or supply opioids resulting in avoidable pain and suffering, particularly for those at the end of life. The beneficial analgesic effects of opioids have been long recognised for centuries, and opioids are usually regarded as some of the most potent analgesics available. Evidence for the benefits of opioids in acute pain and pain at the end of life is substantial, but there remain many unanswered questions about the appropriate use of opioids for non-cancer pains in the long-term, particularly, the lack of data demonstrating long-term effectiveness and the potential for opioids therapy to result in dose-related harms. In addition, the association between opioids and addiction have an equally long history, with varying degrees of societal acceptance or legal control towards recreational use of opioids. Prescribing opioid medicines for pain should reflect good principles in prescribing generally and should be similar to prescribing medicines for other long-term conditions, such as hypertension, diabetes mellitus or asthma. It is essential for both patients and healthcare professionals to have realistic expectations of the intended benefits of any treatment including a trial of opioids. If any medicine, including opioids, fails to attenuate the symptoms for which they are prescribed, they should be tapered and stopped. Changing clinical practice in opioid prescribing is not going to be quick or easy. Providing knowledge and improved understanding is important, but they are only the first small steps required in order to support the cultural changes in healthcare and society that are required in order to ensure that opioid use does not become regulated even more. The principles of the World Health Organization (WHO) analgesic ladder in which increasingly strong medicines are prescribed according to reported pain intensity improved the lives of thousands of patients living with cancer. Treating persistent pain is much more complex given the myriad experiences that shape the perception of pain and its likely trajectory. We need to embrace new ways of thinking about pain with a better understanding of patient needs and attention to the important principle that causing harm with medicines is worse than doing nothing.