Quality prescribing for chronic pain: guide for improvement 2026-2029

10. Opioid management general principles

Reducing long-term opioids can be difficult and individuals may be concerned about withdrawal symptoms and increased pain. Engagement is essential, so give individuals as much control over the process as possible. Poorly managed opioid reduction has the potential to result in negative consequences. Many people with chronic pain taking long-term opioids have anxiety and depression. These may temporarily worsen during opioid reduction, so safety-netting is essential.

10.1 Key reasons for considering opioid reduction/ withdrawal in people with chronic non cancer pain

Opioids are appropriate analgesics for acute pain and for pain at the end of life but there is little evidence that they are helpful for long term pain. There are many side effects and known long term harms associated with opioids. The risk of harm increases substantially at doses above an oral morphine equivalent dose (MED) of 120mg/day, with no increased benefit. If an individual has pain that remains severe despite opioid treatment, the medication is not effective and should be stopped, even if no other treatment is available.66

10.2 Identifying people who would most benefit from a review of their opioid medication and a discussion around tapering/ stopping opioids

Consider inviting individuals on long-term opioids or combinations, such as opioids and benzodiazepines, for a medication review. All people on an opioid should have a review of their treatment, prioritising individuals prescribed more than 50mg morphine equivalent dose (MED), who should be reviewed at least annually to consider ongoing effectiveness and potential harms, due to lack of evidence to support long-term use.

In primary care, searches for specific medications or combinations can be carried out using the Scottish Therapeutics Utility (STU) or GP practice computer systems.

Other individuals who may benefit from a review of their opioid medication would be those with a mental health diagnosis, frailty, drug seeking behaviors, conditions such as sleep apnoea or in people who don’t have a clear, defined diagnosis to support their prescription.

See Appendix E for example letters to patients.

10.3 Deprescribing top tips

Deprescribing of opioids can be challenging for both prescribers and individuals living with chronic pain. It can often be a lengthy time-consuming process. It can be perceived as an area which is too difficult to tackle and difficult to achieve. However, there are many useful resources and websites with guidance on how best to approach the deprescribing of opioids such as:

• NHS Nottinghamshire prescribing committee opioid deprescribing guidance
• The Oxford University Hospitals guidance for reduction of opioids in primary care
• NHS Doncaster Clinical Commissioning Group position statement on opioid prescribing

An effective practice wide deprescribing strategy can be achieved by:

• Adopting a whole team approach to ensure a unified effort
• Including administration staff in briefings and communicating with local community pharmacies to let them know practice plans
• Having a meeting with the multidisciplinary team (MDT) highlighting chronic pain management resources such as Live Well With Pain Ten Footsteps- practitioner guide
• Discussing chronic pain management guidelines such as Scottish Government, NICE and SIGN guidelines
• Discussing local and Board level opioid prescribing and deprescribing protocols such as NHS GGC Guideline- Medication safety in opioid prescribing for chronic non malignant pain
• Develop a practice protocol for opioids to include guidance on starting, prescribing, reviewing and stopping opioids. See example protocol in Appendix D

10.4 Practical steps to reduce high dose opioids

Five practical steps to reduce high dose opioids are:^[110]

1. Education: explain the importance of reducing opioids to the individual

2. Engagement and building rapport: give the individual as much choice as possible around how to reduce their opioids

3. Develop a tapering plan

4. Emotional impact: manage anxiety and depression

5. Expectations: ensure the individual understands that this can be difficult, and that they may need support

See Appendix F for detailed information on each of the five steps.

Adverse effects of medication and increased functioning once medication stopped

Mary, 59 years old, has longstanding joint pain, fibromyalgia, non-Hodgkin’s lymphoma, three basilar tip aneurysms with coiling undertaken and micro-osteoporotic fractures of the pelvis.

Mary came to see her GP and despite all the medication she was on (dihydrocodeine, a fentanyl patch, pregabalin, solifenacin, metoclopramide, duloxetine), her pain score was still 8/10, with side effects of nausea, grey pallor, no energy and daily headaches. She had given up on work and external activities, stopped going on holiday and her eyes were glazed, dull and she looked drowsy. Previous medication had included celecoxib, amitriptyline, co-codamol 8/500, tramadol, gabapentin, oxybutynin, mebeverine, hyoscine, naproxen and a buprenorphine patch.

After a long chat about the effect of chronic pain and with the offer of our support, she agreed to decrease her medication and review how she felt.

Initially the fentanyl patch was changed to co-codamol 30/500 with a review one week later. Although she had no withdrawal symptoms from stopping the patch, she did not feel the co-codamol helped so that was changed to dihydrocodeine 30mg twice a day, and at next review her pain score was down to 5/10. Her headaches had disappeared, she was looking better, her eyes were clearer and Mary was feeling so much better in herself.

Having watched a documentary on the TV about pregabalin, Mary was scared about the effect of pregabalin on her mind and body, and wanted to reduce it down slowly. At her next review her pain was down to 4/10, and with still no headaches she was much brighter in herself and keen to reduce pregabalin down more. She had also returned to work and was talking about organising a holiday abroad.

Unfortunately the headaches recurred, but chronic pain was discussed with her again. As a smoker she was advised to try stopping smoking, and smoking cessation advice and support was given. She was still keen to reduce the pregabalin again and review was set for two weeks. Mary had no ill effects at all from reducing pregabalin, and wished to stop it altogether, because she had no pain during the day and any headaches at night were helped by one dihydrocodeine tablet.

Following the success of reducing these medicines, Mary wished to try reducing her duloxetine next. She did not manage to reduce duloxetine and had to go back up to usual dose. However, she feels very well and her whole demeanour has changed, with good colour, more energy, minimal pain and feels much better in herself. She was working more and by then had a holiday booked.

Over a period of four months, Mary’s medication was reviewed and reduced to duloxetine 60mg daily and dihydrocodeine 30mg at night as required, with a vast difference in her physical, mental and emotional functioning.

10.5 Opioid reduction decision aid

The information below is also available as a flow chart within the supplementary documents associated with this guide.

First step: start with the individual, not the medicine

• Pain Consultation Model and Practice MDT Toolkit
• Inform individual of limits and harms of opioids – consider Opioid Side Effect Lottery leaflet and More Harm than Good leaflets for different opioids
• Explain prescriber responsibility on opioid prescribing – Faculty Pain Medicine and MDDUS advice

Second step: consider the medication

Continue Opioids – safe/ effective

• Opioids helping function +/- pain
• No significant side effects

Advise stopping – ineffective

• Opioids not helping function +/- pain
• Mild/moderate side effects

Practice protocol – harm present

• Opioid not helping function +/- pain
• Significant side effects
• Significant polypharmacy/ harmful drug combinations
• Drug seeking behaviour
• Evidence of diversion

Third step: what is the motivation and self-agency to stop/reduce

Motivated and high self-agency

• Print off paindata deprescribing plan at 10% per /week
• Consider monthly reduction of co-codamol, dihydrocodeine, tramadol
• More Harm than Good leaflet

Low motivation, anxiety, low self-agency

• Pharmacist +/- GP support for follow up
• Consider 5-10% reduction per week
• Consider monthly reduction of co-codamol, dihydrocodeine, tramadol

Declines reduction

• Clarify patient perspective
• Mental health assessment
• Practice MDT discussion
• Pain team advice option

Resources

Paindata taper calculator

Co-codamol reduction leaflet

Increased pain with opioids

Deprescribing GP practice case studies

Oxford guidance for opioid reduction in primary care – 5 E’s approach

Practice protocol for opioid prescribing

10.6 Addressing challenges during reduction

Advice for managing adverse effects

Kindly adapted with permission from NHS Greater and Clyde Opioid Prescribing for Chronic Non Malignant Pain.

If mood deteriorates, anxiety increases or pain escalates, hold the current opioid dose for a further three to four weeks. Avoid reversing the taper or adding in as required opioids or sedatives. Instead, work with them closely to manage their pain and mood using non-pharmacological strategies, consider potential causes and if necessary adjuvant treatments.

If withdrawal symptoms are evident, hold the current opioid dose until completely settled. Most symptoms settle within a couple of weeks but some can persist for several months. Reassure individual that, although uncomfortable, these are rarely medically serious. Consider prescribing symptomatically e.g. smooth muscle relaxants, anti-diarrhoeal, anti-emetic, paracetamol or NSAIDs.

Where there is an unsuccessful taper (the individual defaults from treatment plan or tapering becomes clinically inappropriate), stabilise on lowest appropriate maintenance dose and revisit in three to six months.

10.7 Opioid management in secondary care

Opioids are one of the most prescribed medications in secondary care.^[111] It is important that prescribing follows good opioid stewardship, when organisations show high quality governance in the use of opioids from the level of individual patient care to the organisational level. Secondary care should promote good opioid stewardship in all clinical scenarios.

10.8 Key considerations for good opioid stewardship:8^{,[112], [113],[114]}

A safety review undertaken by the MHRA, and advice from the Commission on Human Medicines (CHM) considered the use of modified release opioids during the post-operative period. The review recommends that modified-release opioids are not used in treatment of acute post-operative pain. Licences for morphine tablets and modified release oxycodone preparations for post-operative pain relief have been withdrawn. This change in licensing reflects concern over significant risks of opioid-induced ventilatory impairment (OIVI) and persistent post-operative opioid use (PPOU).

• An individual’s use of analgesics is assessed^[115] at the start of a secondary care episode. This will include an evaluation of medications taken previously, especially opiates, and any history relating to long term use of analgesic medications. Ongoing use of 90mg Morphine Equivalent Daily Dose (MED), or more, is an indication for specialist involvement37
• Before starting opioid therapy, it is helpful to discuss the expectations and duration
• Where applicable, a multimodal approach to analgesia will often be most effective and will minimise side effects
• In general, long-acting opioid preparations (modified release) are avoided, in recognition of the associated risks of tolerance and dependence. The MHRA Public Assessment Report (2025) on modified release opioids and treatment of post-operative pain provides more detail
• Assessment of adequacy of pain relief will rely heavily on assessment of functional ability, rather than numerical pain scores. This reflects the changing emphasis towards prioritising and promoting recovery of function
• Duration of opioid therapy is, in most cases, expected to be five to seven days or less.^[116] Longer courses of opioid therapy carry risks of long-term dependence
• Opioid analgesics prescribed on hospital discharge should be of limited duration. It should be clear, and communicated to both individual and GP, that opioids are not expected to continue in the long term
• Good communication between primary and secondary care is a key facilitator of high-quality care. This makes it easier to avoid unintended continued use of opioids, and to manage other considerations such as problematic substance use and diversion

10.9 Surgical Analgesia

Perioperative analgesia can be a source of uncertainty and anxiety for people. Chronic use of opioids is associated with tolerance and opioid-induced hyperalgesia, which is increasingly recognised. These phenomena reduce the analgesic efficacy of peri-operative opioids and are associated with increased risk of peri-operative complications.

Planning for pain management ^[117] is an important part of the wider preparation for surgery and minimising opioid-related harm [118] and should be communicated to primary care where specific requirements have been identified for the care of an individual. Good practice points are further described in the Faculty of Pain Medicine Best Practice Guidelines 2021. As stated in the March 2025 MHRA Safety Roundup, prolonged-release opioids are no longer recommended for relief of post-operative pain.

10.10 Pre-operatively

Identify individuals whose pain management may be complex and seek specialist advice.117 People taking long term opioids can be at risk of sub-optimal analgesia and peri-operative complications. These complications include immunosuppression, endocrine and metabolic effects. Pre-operative tapering of opioids may facilitate post-operative pain relief and can be considered if timing permits.^[119]

Utilise non-pharmacological techniques to optimise function and support – education, social and psychological support, relaxation techniques may all have a role.

10.11 Perioperatively

A multimodal analgesic approach is recommended, with minimisation of opioid use. Other drug classes and regional analgesia may be recommended.118

10.12 Post-operatively

Early mobilisation and psychological support are important. Multimodal analgesia with the least possible use of opioids is recommended. Modified-release preparations are no longer recommended and should not be used. After surgery, most individuals only see benefit from opioid therapy for five to seven days. No more than seven days’ treatment with opioids is recommended.^[120]

Individuals should be reviewed when opioids are continued for longer than seven days. This may require specialist input and should consider:116

• high levels of anxiety, depression or catastrophising pre-operatively or post-operatively
• ongoing surgical issues such as infection/ surgical abdomen, etc, that need to be assessed clinically
• pre-operative chronic pain
• pre-operative opioids
• problematic substance use
• if this is an early sign of development of chronic post-surgical pain or persistent post-operative opioid use

Further structured recommendations for the management of opioids in the peri-operative period are given by the Faculty of Pain Medicine^[121] and by NHS Lothian.

10.13 On Discharge

Clear expectations should be set that opioids are not expected to be of benefit for longer than seven days for most people, and this is communicated to the individual and their GP. Although different discharge prescribing systems are in use across Scotland, the expectations for pain trajectory and opioid use (dose and duration) should be clearly stated.

10.14 Opioid reduction in other secondary care situations

Opioid reduction requires an effective clinical relationship and time. The average length of stay for inpatients in Scotland has been reducing over recent decades^[122] and this is replicated across the developed world. For those who have been taking opioids long term it is unlikely that reduction of long-term opioid use can be completed during most peoples’ admissions. However, inpatient treatment plans should be sympathetic to the individual’s previous use of opioids and to their needs on discharge. In longer admissions, secondary care management can use the same approach to reduce opioid use as those used in primary care.

10.15 Discharge documentation

Clear communication is crucial to ensure safe transition between primary and secondary care. Discharge instructions for opioids should specify the current changes, expected reduction plan and the supply given. Updating resources such as the Emergency Care Summary (ECS) and the Key Information Summary (KIS) will improve understanding of an individual’s history and future needs, especially in the event of a future unplanned admission.