Long‐Term Spinal Opioid Therapy in Terminally Ill Cancer Pain Patients

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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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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Monitoring outcomes during long-term opioid therapy for noncancer pain: Results with the Pain Assessment and Documentation Tool

Journal of Opioid Management ◽

10.5055/jom.2005.0055 ◽

2005 ◽

Vol 1 (5) ◽

pp. 257 ◽

Cited By ~ 53

Author(s):

Steven D. Passik, PhD ◽

Kenneth L. Kirsh, PhD ◽

Laurie Whitcomb, MA ◽

Jeffrey R. Schein, PhD, MPH ◽

Mitchell A. Kaplan, PhD ◽

...

Keyword(s):

Chronic Pain ◽

Side Effects ◽

Pain Assessment ◽

The United States ◽

Opioid Therapy ◽

Chronic Pain Patients ◽

Noncancer Pain ◽

Documentation Tool ◽

Pain Patients

The increasingly common practice of long-term opioid therapy for chronic noncancer pain must be guided by ongoing assessment of four types of outcomes: pain relief, function, side effects, and drug-related behaviors. Our objective was to gather initial pilot data on the clinical application of a specialized chart note, the Pain Assessment and Documentation Tool (PADT), which was developed and tested with 27 physicians. This pilot test provided the means to collect cross-sectional outcome data on a large sample of opioid-treated chronic pain patients. Each of the physician volunteers (located in a variety of settings across the United States) completed the PADT for a convenience sample of personally treated chronic pain patients who had received at least three months of opioid therapy. Completion of the PADT required a clinical interview, review of the medical chart, and direct clinical observation. Data from the PADTs were collated and analyzed. The results suggested that the majority of patients with chronic pain achieve relatively positive outcomes in the eyes of their prescribing physicians in all four relevant domains with opioid therapy. Analgesia was modest but meaningful, functionality was generally stabilized or improved, and side effects were tolerable. Potentially aberrant behaviors were common but viewed as an indicator of a problem (i.e., addiction or diversion) in only approximately 10 percent of cases. Using the PADT, physician ratings can be developed in four domains. In this sample, outcomes suggested that opioid therapy provided meaningful analgesia.

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Predictive Value of Intrathecal Narcotic Trials for Long-Term Therapy with Implantable Drug Administration Systems in Chronic Non-Cancer Pain Patients

Pain Practice ◽

10.1046/j.1533-2500.2002.02040.x ◽

2002 ◽

Vol 2 (4) ◽

pp. 315-325 ◽

Cited By ~ 20

Author(s):

Eric Dominguez ◽

Bolkar Sahinler ◽

Deeni Bassam ◽

Miles Day ◽

Leland Lou ◽

...

Keyword(s):

Cancer Pain ◽

Drug Administration ◽

Predictive Value ◽

Term Therapy ◽

Long Term Therapy ◽

Pain Patients

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Monitoring of opioid therapy in advanced cancer pain patients

Journal of Pain and Symptom Management ◽

10.1016/s0885-3924(96)00302-8 ◽

1997 ◽

Vol 13 (4) ◽

pp. 204-212 ◽

Cited By ~ 51

Author(s):

Sebastiano Mercadante ◽

Gabriella Dardanoni ◽

Leonardo Salvaggio ◽

Maria Gabriella Armata ◽

Antonio Agnello

Keyword(s):

Cancer Pain ◽

Advanced Cancer ◽

Opioid Therapy ◽

Pain Patients

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Monitoring Opioid Adherence in Chronic Pain Patients: Assessment of Risk of Substance Misuse

January 2018 - Pain Physician ◽

10.36076/ppj.2011/14/e119 ◽

2011 ◽

Vol 3;14 (2;3) ◽

pp. E119-E131

Author(s):

Daneshvari R. Solanki

Keyword(s):

Chronic Pain ◽

Cancer Pain ◽

Comparative Studies ◽

Opioid Therapy ◽

Screening Tools ◽

Cochrane Library ◽

Simultaneous Increase ◽

The Many ◽

Adherence Monitoring ◽

Pain Patients

Background: Use of opioids for chronic non-cancer pain (CNCP) has increased in recent years because this pain had been undertreated. There was also a simultaneous increase in misuse and abuse of opioids. Deaths due to such abuse and misuse also have risen as seen in the many reports published every day in local papers as well as in the medical literature. So, it is imperative that patients who are prescribed these medications be monitored for adherence so misuse and abuse can be curtailed and opioids are available to those who genuinely need them for chronic pain control. There are various screening tools available to monitor such adherence, and there is an abundance of literature about it in addiction and psychiatric medicine. There is, though, a paucity of such literature as applied to pain medicine. Objectives: Our objectives for this review were twofold. We wanted to identify which screening tools are available to monitor opioid adherence and we wanted to see if there were prospective comparative studies of these tools to identify a single best tool that can be applied to all chronic non-cancer pain patients managed with opioids. Study Design: We did a review of the current literature about monitoring of opioid adherence. We also looked at their use, validity, and comparative studies. Methods: We performed a literature search using PubMed, EMBASE, and the Cochrane library. The search was conducted using the terms opioids, non-cancer pain, monitoring, and adherence. The databases from 1996 to November 2010 were reviewed. The search included prospective and retrospective studies, review articles, and FDA records. Bibliographies and cross references were reviewed when deemed appropriate. Conclusion: We found 52 publications, of which 22 met the criteria to be included in this manuscript. We found only one study that was prospective, and compared the various screening tools that are available to monitor opioid adherence. In the majority of the studies the number treated was small. There was not a single screening tool that can be applied universally to all patients who are on opioid therapy for chronic non-cancer pain. Key words: Opioids, chronic pain, chronic non-cancer pain, opioid adherence, monitoring of opioid adherence, controlled substances, prescription monitoring programs, screening tools

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