Opioid therapy for chronic non-cancer pain: Does typology of risk predict aberrant behaviour?

Abstract Background: The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (COG) was developed in response to increasing rates of opioid-related hospital visits and deaths in Canada, and uncertain benefits of opioids for chronic non-cancer pain (CNCP). Following publication, we developed a list of evaluable outcomes to assess the impact of this guideline on practice and patient outcomes . Methods: A working group at the National Pain Centre at McMaster University used a modified Delphi process to construct a list of clinical and patient outcomes important in assessing the uptake and application of the COG. An advisory group then reviewed this list to determine the relevance and feasibility of each outcome, and identified potential data sources. This feedback was reviewed by the National Faculty for the Guideline, and a National Advisory Group that included the creators of the COG, resulting in the final list of 5 priority outcomes. Results: Five outcomes were judged clinically important and feasible to measure: 1) Effects of opioids for CNCP on quality of life, 2) Assessment of patient’s risk of addiction before starting opioid therapy, 3) Monitoring patients on opioid therapy for aberrant drug-related behaviour, 4) Mortality rates associated with prescription opioid overdose and 5) Use of treatment agreements with patients before initiating opioid therapy for CNCP. Data sources for these outcomes included patient’s medical charts, e-Opioid Manager, prescription monitoring programs and administrative databases. Conclusion: Measuring the impact of best practice guidelines is infrequently done. Future research should consider capturing the five outcomes identified in this study to evaluate the impact of the COG in promoting evidence-based use of opioids for CNCP.

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A Systematic Review of Randomized Trials of Long-Term Opioid Management for Chronic Non-Cancer Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2011/14/91 ◽

2011 ◽

Vol 3;14 (2;3) ◽

pp. 91-121

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Systematic Review ◽

Cancer Pain ◽

Systematic Reviews ◽

Randomized Trials ◽

Opioid Therapy ◽

Functional Improvement ◽

Controlled Trials ◽

Chronic Opioid Therapy ◽

Level Of Evidence

Background: Even though opioids have been used for pain for thousands of years, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependance, or abuse. While the debate continues, the use of chronic opioid therapy for chronic non-cancer pain has increased exponentially. Even though evidence is limited, multiple expert panels have concluded that chronic opioid therapy can be effective therapy for carefully selected and monitored patients with chronic non-cancer pain. Study Design: A systematic review of randomized trials of opioid management for chronic noncancer pain. Objective: The objective of this systematic review is to evaluate the clinical efficacy of opioids in the treatment of chronic non-cancer pain. Methods: A comprehensive evaluation of the literature relating to opioids in chronic non-cancer pain was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs) and Jadad criteria. A literature search was conducted by using PubMed, EMBASE, Cochrane library, ECRI Institute Library, U.S. Food and Drug Administration (FDA) website, U.S. National Guideline Clearinghouse (NGC), Database of Abstracts of Reviews of Effectiveness (DARE), clinical trials, systematic reviews and cross references from systematic reviews. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) and used by other systematic reviews and guidelines. Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, withdrawals, and adverse effects. Results: Based on the USPSTF criteria, the indicated level of evidence was fair for Tramadol in managing osteoarthritis. For all the drugs assessed, including Tramadol, for all other conditions, the evidence was poor based on either weak positive evidence, indeterminate evidence, or negative evidence. Limitations: A paucity of literature, specifically with follow-up beyond 12 weeks for all types of opioids with controlled trials for various chronic non-cancer pain conditions. Conclusions: This systematic review illustrated fair evidence for Tramadol in managing osteoarthritis with poor evidence for all other drugs and conditions. Thus, recommendations must be based on non-randomized studies. Key words: Chronic non-cancer pain, opioids, opioid efficacy, opioid effectiveness, significant pain relief, functional improvement, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, buprenorphine, methadone, tapentadol, oxycodone, oxymorphone, systematic reviews, randomized trials

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Muscle function following testosterone replacement in men on opioid therapy for chronic non‐cancer pain ‐ a randomized controlled trial

Andrology ◽

10.1111/andr.13147 ◽

2021 ◽

Author(s):

Mikkel Iwanoff Kolind ◽

Louise Lehmann Christensen ◽

Paolo Caserotti ◽

Marianne Skovsager Andersen ◽

Dorte Glintborg

Keyword(s):

Randomized Controlled Trial ◽

Cancer Pain ◽

Muscle Function ◽

Controlled Trial ◽

Opioid Therapy ◽

Testosterone Replacement ◽

Randomized Controlled

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Cancer Pain Management, Principles of Opioid Therapy, Dosing Guidelines

Encyclopedia of Pain ◽

10.1007/978-3-642-28753-4_540 ◽

2013 ◽

pp. 390-392

Author(s):

James F. Cleary

Keyword(s):

Pain Management ◽

Cancer Pain ◽

Opioid Therapy ◽

Cancer Pain Management

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Random urine drug testing among patients receiving opioid therapy for cancer pain

Cancer ◽

10.1002/cncr.33326 ◽

2020 ◽

Author(s):

Joseph A. Arthur ◽

Michael Tang ◽

Zhanni Lu ◽

David Hui ◽

Kristy Nguyen ◽

...

Keyword(s):

Cancer Pain ◽

Drug Testing ◽

Opioid Therapy ◽

Urine Drug Testing ◽

Urine Drug

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Geographic Variation in Health Service Use and Perceived Access Barriers for Australian Adults with Chronic Non-Cancer Pain Receiving Opioid Therapy

Pain Medicine ◽

10.1093/pm/pnw109 ◽

2016 ◽

Vol 17 (11) ◽

pp. 2003-2016 ◽

Cited By ~ 5

Author(s):

Amy Peacock ◽

Suzanne Nielsen ◽

Raimondo Bruno ◽

Gabrielle Campbell ◽

Briony Larance ◽

...

Keyword(s):

Health Service ◽

Cancer Pain ◽

Geographic Variation ◽

Service Use ◽

Opioid Therapy ◽

Health Service Use ◽

Access Barriers ◽

Perceived Access

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Identifying appropriate outcomes to help evaluate the impact of the Canadian Guideline for Safe and Effective Use of Opioids for Non-Cancer Pain

BMC Anesthesiology ◽

10.1186/s12871-020-0930-4 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Michael Allen ◽

Beth Sproule ◽

Peter MacDougall ◽

Andrea Furlan ◽

Laura Murphy ◽

...

Keyword(s):

Cancer Pain ◽

Patient Outcomes ◽

Opioid Therapy ◽

Data Sources ◽

Prescription Opioid ◽

Advisory Group ◽

Opioid Overdose ◽

Canadian Guideline ◽

Effective Use ◽

The Impact

Abstract Background The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain (COG) was developed in response to increasing rates of opioid-related hospital visits and deaths in Canada, and uncertain benefits of opioids for chronic non-cancer pain (CNCP). Following publication, we developed a list of evaluable outcomes to assess the impact of this guideline on practice and patient outcomes. Methods A working group at the National Pain Centre at McMaster University used a modified Delphi process to construct a list of clinical and patient outcomes important in assessing the uptake and application of the COG. An advisory group then reviewed this list to determine the relevance and feasibility of each outcome, and identified potential data sources. This feedback was reviewed by the National Faculty for the Guideline, and a National Advisory Group that included the creators of the COG, resulting in the final list of 5 priority outcomes. Results Five outcomes were judged clinically important and feasible to measure: 1) Effects of opioids for CNCP on quality of life, 2) Assessment of patient’s risk of addiction before starting opioid therapy, 3) Monitoring patients on opioid therapy for aberrant drug-related behaviour, 4) Mortality rates associated with prescription opioid overdose and 5) Use of treatment agreements with patients before initiating opioid therapy for CNCP. Data sources for these outcomes included patient’s medical charts, e-Opioid Manager, prescription monitoring programs and administrative databases. Conclusion Measuring the impact of best practice guidelines is infrequently done. Future research should consider capturing the five outcomes identified in this study to evaluate the impact of the COG in promoting evidence-based use of opioids for CNCP.

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All-cause mortality in patients with long-term opioid therapy compared with non-opioid analgesics for chronic non-cancer pain: a database study

BMC Medicine ◽

10.1186/s12916-020-01644-4 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Winfried Häuser ◽

Tino Schubert ◽

Tobias Vogelmann ◽

Christoph Maier ◽

Mary-Ann Fitzcharles ◽

...

Keyword(s):

Cancer Pain ◽

Opioid Analgesics ◽

Opioid Therapy ◽

Database Study ◽

All Cause Mortality

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Health service utilisation by people living with chronic non-cancer pain: findings from the Pain and Opioids IN Treatment (POINT) study

Australian Health Review ◽

10.1071/ah15047 ◽

2016 ◽

Vol 40 (5) ◽

pp. 490 ◽

Cited By ~ 3

Author(s):

Suzanne Nielsen ◽

Gabrielle Campbell ◽

Amy Peacock ◽

Kimberly Smith ◽

Raimondo Bruno ◽

...

Keyword(s):

Health Insurance ◽

Cancer Pain ◽

Private Health Insurance ◽

Healthcare Services ◽

Opioid Therapy ◽

Limited Evidence ◽

Financial Barriers ◽

Different Types ◽

Before And After

Objective The aims of the present study were to describe the use, and barriers to the use, of non-medication pain therapies and to identify the demographic and clinical correlates of different non-opioid pain treatments. Methods The study was performed on a cohort (n = 1514) of people prescribed pharmaceutical opioids for chronic non-cancer pain (CNCP). Participants reported lifetime and past month use of healthcare services, mental and physical health, pain characteristics, current oral morphine equivalent daily doses and financial and access barriers to healthcare services. Results Participants reported the use of non-opioid pain treatments, both before and after commencing opioid therapy. Services accessed most in the past month were complementary and alternative medicines (CAMs; 41%), physiotherapy (16%) and medical and/or pain specialists (15%). Higher opioid dose was associated with increased financial and access barriers to non-opioid treatment. Multivariate analyses indicated being younger, female and having private health insurance were the factors most commonly associated with accessing non-opioid treatments. Conclusions Patients on long-term opioid therapy report using multiple types of pain treatments. High rates of CAM use are concerning given limited evidence of efficacy for some therapies and the low-income status of most people with CNCP. Financial and insurance barriers highlight the importance of considering how different types of treatments are paid for and subsidised. What is known about the topic? Given concerns regarding long-term efficacy, adverse side-effects and risk of misuse and dependence, prescribing guidelines recommend caution in prescribing pharmaceutical opioids in cases of CNCP, typically advising a multidisciplinary approach to treatment. There is a range of evidence supporting different (non-drug) treatment approaches for CNCP to reduce pain severity and increase functioning. However, little is known about the non-opioid treatments used among those with CNCP and the demographic and clinical characteristics that may be associated with the use of different types of treatments. Understanding the use of non-drug therapy among people with CNCP is crucial given the potential to improve pain control for these patients. What does this paper add? The present study found that a wide range of non-opioid treatments was accessed by the study sample, both before and after commencing opioids, indicating that in this sample opioids were not the sole strategy used for pain management. The most common treatment (other than opioids) was CAM, reported by two-fifths of the sample. Having private health insurance was associated with increased use of non-opioid treatments for pain, highlighting the importance of considering how treatments are paid for and potential financial barriers to effective treatments. What are the implications for practitioners? Patients’ beliefs and financial barriers may affect the uptake of different treatments. Many patients may be using complementary and alternative approaches with limited evidence to support their use, highlighting the need for clinicians to discuss with patients the range of prescribed and non-prescribed treatments they are accessing and to help them understand the benefits and risks of treatments that have not been tested sufficiently, or have inconsistent evidence, as to their efficacy in improving pain outcomes.

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