Is there a place for asneeded opioid dosing versus regular bytheclock administration in the treatment of CNCP

Although most patients are prescribed regular, by-the-clock opioids for CNCP, in practice it is not unusual for patients to skip doses when their pain is not as severe, effectively giving themselves (and their receptors) a short opioid holiday. In one review, up to 90 percent of patients with CNCP intermittently stopped or missed opioid doses with only 15 percent developing withdrawal symptoms.60 In an RCT by the same authors, only 30 percent of patients with CNCP developed (usually mild) withdrawal symptoms following placebo interruption of their long-term opioid therapy for 60 hours.61[II]

Given that not all CNCP is continuous or of the same intensity over time, it may be reasonable for patients to skip doses, at least within a 24-hour period, without substantial risk of developing withdrawal symptoms. In theory, these short opioid holidays may allow opioid receptors time to recover from being constantly bombarded by agonists (perhaps developing less tolerance or hyperalgesia). However, no trials have been performed to determine if as-needed opioid dosing is as effective or has any advantages (such as dose reduction or fewer side effects) over regular opioid dosing in the treatment of CNCP. When prescribing methadone to patients with CNCP, they should be cautioned about reducing their restart dose if they miss more than two days of metha-done (see above under Methadone).

Is there a place for multimodal analgesia including fixed-dose combinations (e.g. codeine-paracetamol or combined opioid-opioid analgesia?

Multimodal analgesia is defined as the use of two or more analgesic drugs or techniques to improve analgesic efficacy and/or reduce adverse effects. This concept has been trialled extensively and found to be beneficial in acute pain management, but data for the treatment of CNCP are limited. Multimodal analgesia may take the form of either flexible or fixed-dose opioid, paracetamol, or NSAID combinations, or the use of adjuvant agents, such as ketamine or gabapentin.

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