Effectiveness of Opioids in the Treatment of
Chronic Non-Cancer Pain

For thousands of years, opioids have been used to treat pain, and they continue to be one of the most commonly prescribed medications for pain. It is estimated that 90% of patients presenting to pain centers and receiving treatment in such facilities are on opioids. Opioids can be considered broad-spectrum analgesics that act at multiple points along the pain pathway. Unfortunately, opioids also have the potential for great harm, with multiple side effects and potential complications, some of which are lethal. They are also uniquely addictive, which can lead to misuse and diversion. We reviewed the relevant English literature and did thorough manual searches of the bibliographies of known primary and review articles. We utilized pain relief as the primary outcome measure. Other outcome measures were functional improvement, improvement of psychological status, improvement in work status, and evidence of addiction. Shortterm use and improvement was defined as less than 6 months and long-term relief was defined as 6 months or longer. The 3 systematic reviews evaluating long-term effectiveness of opioids for chronic noncancer pain provided unclear and weak evidence. The results of this review showed that many patients in the included studies were dissatisfied with adverse events or insufficient pain relief from opioids and withdrew from the studies. For patients able to continue on opioids, evidence was weak suggesting that their pain scores were lower than before therapy and that this relief could be maintained long-term (> 6 months). There was also weak evidence that long-term opioid therapy with morphine and transdermal fentanyl not only decreases pain but also improves functioning. Limited evidence was available for the most commonly used opioids, oxycodone and hydrocodone. Evidence for the ability to drive on chronic opioid therapy was moderate without major side effects or complications. It is concluded that, for long-term opioid therapy of 6 months or longer in managing chronic non-cancer pain, with improvement in function and reduction in pain, there is weak evidence for morphine and transdermal fentanyl. However, there is limited or lack of evidence for all other controlled substances, including the most commonly used drugs, oxycodone and hydrocodone. Key words: Opioids, opioid effectiveness, pain relief, functional improvement, adverse effects, codeine, morphine, hydrocodone, hydromorphone, fentanyl, methadone.

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A Systematic Review of Randomized Trials on the Effectiveness of Opioids for Cancer Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2012/15/es39 ◽

2012 ◽

Vol 3S;15 (3S;7) ◽

pp. ES39-ES58 ◽

Cited By ~ 1

Author(s):

Lakshmi Koyyalagunta

Keyword(s):

United States ◽

Systematic Review ◽

Side Effects ◽

Pain Relief ◽

Cancer Pain ◽

Outcome Measures ◽

Randomized Trials ◽

Transdermal Fentanyl

Background: In all recommended guidelines put forth for the treatment of cancer pain, opioids continue to be an important part of a physician’s armamentarium. Though opioids are used regularly for cancer pain, there is a paucity of literature proving efficacy for long-term use. Cancer is no longer considered a “terminal disease”; 50% to 65% of patients survive for at least 2 years, and there are about 12 million cancer survivors in the United States. There is a concern about side effects, tolerance, abuse and addiction with long-term opioid use and a need to evaluate the effectiveness of opioids for cancer pain. Objective: The objective of this systematic review was to look at the effectiveness of opioids for cancer pain. Study Design: A systematic review of randomized trials of opioids for cancer pain. Methods: A comprehensive review of the current literature for randomized controlled trials (RCTs) of opioids for cancer pain was done. The literature search was done using PubMed, EMBASE, Cochrane library, clinical trials, national clearing house, Web of Science, previous narrative systematic reviews, and cross references. The studies were assessed using the modified Cochrane and Jadad criteria. Analysis of evidence was done utilizing the modified quality of evidence developed by United States Preventive Services Task Force (USPSTF). Outcome Measures: Pain relief was the primary outcome measure. Secondary outcome measures are quality of life (QoL) and side effects including tolerance and addiction. Results: The level of evidence for pain relief based on the USPSTF criteria was fair for transdermal fentanyl and poor for morphine, tramadol, oxycodone, methadone, and codeine. Limitations: Randomized trials in a cancer setting are difficult to perform and justify. There is a paucity of long-term trials and this review included a follow-up period of only 4 weeks. Conclusion: This systematic review of RCTs of opioids for cancer pain showed fair evidence for the efficacy of transdermal fentanyl and poor evidence for morphine, tramadol, oxycodone, methadone, and codeine. Key words: Opioids, pain relief, cancer pain, morphine, hydromorphone, methadone, fentanyl, oxymorphone, hydrocodone, oxycodone, buprenorphine.

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Perspectives of pain specialists, patients, and family members on long-term opioid use for chronic non-cancer pain: a qualitative study

BMC Anesthesiology ◽

10.1186/s12871-021-01501-8 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Rattaphol Seangrung ◽

Thongchai Tempeetikul ◽

Supasit Pannarunothai ◽

Supalak Sakdanuwatwong

Keyword(s):

Pain Management ◽

Pain Relief ◽

Qualitative Study ◽

Adverse Events ◽

Cancer Pain ◽

Family Members ◽

Opioid Therapy ◽

Functional Improvement ◽

Opioid Use

Abstract Background Opioids are currently prescribed for chronic non-cancer pain (CNCP), and some patients use opioids continuously for long-term treatment. Stakeholders’ awareness about long-term opioid therapy is essential for improving the safety and effectiveness of pain treatment. The purpose of this study is to explore the perspectives of pain specialists, patients, and family caregivers about long-term opioid use in CNCP management. Methods This study was a qualitative study and adhered to the COREQ guidelines. Pain specialists (n = 12), patients (n = 14), and family members (n = 9) were recruited to the study by purposive sampling at the Pain Clinic of Ramathibodi Hospital. Semi-structured interviews were recorded, verbatim transcribed, conceptually coded, and analyzed using Atlas.ti 8.0. Results All groups of participants described opioids as non-first-line drugs for pain management. Opioids should be prescribed only for severe pain, when non-opioid pharmacotherapy and non-pharmacological therapies are not effective. Patients reported that the benefits of opioids were for pain relief, while physicians and most family members highlighted that opioid use should improve functional outcomes. Physicians and family members expressed concerns about opioid-related side effects, harm, and adverse events, while patients did not. Patients confirmed that they would continue using opioids for pain management under supervision. However, physicians stated that they would taper off or discontinue opioid therapy if patients’ pain relief or functional improvement was not achieved. Both patients and family members were willing to consider non-pharmacological therapies if potential benefits existed. Patient education, doctor–patient/family relationships, and opioid prescription policies were proposed to enhance CNCP management. Conclusion Long-term opioid therapy for CNCP may be beneficial in patients who have established realistic treatment goals (for both pain relief and functional improvement) with their physicians. Regular monitoring and evaluation of the risks and benefits, adverse events, and drug-related aberrant behaviors are necessary. Integrated multimodal multidisciplinary therapies and family member collaborations are also important for improving CNCP management.

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Perspectives of Pain Specialists, Patients, and Family Members on Long-Term Opioid use for Chronic Non- Cancer Pain: A Qualitative Study

10.21203/rs.3.rs-916542/v1 ◽

2021 ◽

Author(s):

Rattaphol Seangrung ◽

Thongchai Tempeetikul ◽

Supasit Pannarunothai ◽

Supalak Sakdanuwatwong

Keyword(s):

Pain Management ◽

Pain Relief ◽

Qualitative Study ◽

Adverse Events ◽

Cancer Pain ◽

Family Members ◽

Opioid Therapy ◽

Functional Improvement ◽

Opioid Use

Abstract Background: Opioids are currently prescribed for chronic non-cancer pain (CNCP), and some patients use opioids continuously for long-term treatment. Stakeholders’ awareness about long-term opioid therapy is essential for improving the safety and effectiveness of pain treatment. The purpose of this study is to explore the perspectives of pain specialists, patients, and family caregivers about long-term opioid use in CNCP management.Methods: This study was a qualitative study and adhered to the COREQ guidelines. Pain specialists (n = 12), patients (n = 14), and family members (n = 9) were recruited to the study by purposive sampling at the Pain Clinic of Ramathibodi Hospital. Semi-structured interviews were recorded, verbatim transcribed, conceptually coded, and analyzed using Atlas.ti 8.0.Results: All groups of participants described opioids as non-first-line drugs for pain management. Opioids should be prescribed only for severe pain, when non-opioid pharmacotherapy and non-pharmacological therapies are not effective. Patients reported that the benefits of opioids were for pain relief, while physicians and most family members highlighted that opioid use should improve functional outcomes. Physicians and family members expressed concerns about opioid-related side effects, harm, and adverse events, while patients did not. Patients confirmed that they would continue using opioids for pain management under supervision. However, physicians stated that they would taper off or discontinue opioid therapy if patients’ pain relief or functional improvement was not achieved. Both patients and family members were willing to consider non-pharmacological therapies if potential benefits existed. Patient education, doctor–patient/family relationships, and opioid prescription policies were proposed to enhance CNCP management.Conclusion: Long-term opioid therapy for CNCP may be beneficial in patients who have established realistic treatment goals (for both pain relief and functional improvement) with their physicians. Regular monitoring and evaluation of the risks and benefits, adverse events, and drug-related aberrant behaviors are necessary. Integrated multimodal multidisciplinary therapies and family member collaborations are also important for improving CNCP management.

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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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Chronic Use of Opioids for Nonmalignant pain: A Prospective Study

Pain Research and Management ◽

10.1155/1997/279307 ◽

1997 ◽

Vol 2 (2) ◽

pp. 101-107 ◽

Cited By ~ 2

Author(s):

Perry N Fuchs ◽

Ann Gamsa

Keyword(s):

Substance Abuse ◽

Side Effects ◽

Pain Relief ◽

Pain Intensity ◽

Leisure Activities ◽

Opioid Therapy ◽

Social Activities ◽

Nonmalignant Pain ◽

Chronic Nonmalignant Pain

OBJECTIVE: To assess the effects of long term opioid therapy on pain, mood, and social and leisure activities in patients with chronic nonmalignant pain.METHODS: Fourteen patients (eight males and six females) were treated with opioid medications for chronic nonmalignant pain not improved by previous treatments. Baseline measures of pain intensity were obtained before introducing opioids. Patients were monitored throughout the study, with outcome measured four to 32 months after opioids were started. The final measures examined drug dose, side effects, pain level, pain relief, emotional status, and involvement in social and leisure activities.RESULTS: A total of 64.3% of patients reported good to excellent pain relief with opioid medication, and 64.3% reported reduced pain intensity, the decrease ranging from 25% to 100% (from baseline measures) on a scale rated from 0 to 10. As well, 64.3% scored their emotional state as 5 or better on the 0 to 10 scale (0 indicating greatest distress), and 64.3% reported at least moderate (at least 5 on the 0 to 10 scale) involvement in leisure and social activities. There was a significant negative correlation between pain intensity and amount of leisure and social activity; 88.9% of patients who reported moderate to full involvement in leisure and social activities also noted decreased pain on the 0 to 10 scale. Other than one patient who developed tolerance, there were no notable problems with dose escalation or with any other form of substance abuse.CONCLUSIONS: Some patients with chronic nonmalignant pain benefit from long term opioid therapy without developing unmanageable side effects, tolerance or substance abuse problems. These results, together with previous findings, show that opioids can be a safe and useful long term treatment for chronic nonmalignant pain.

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Chronic Noncancer Pain and the Long Term Utility of Opioids

Pain Research and Management ◽

10.1155/2004/304094 ◽

2004 ◽

Vol 9 (1) ◽

pp. 19-24 ◽

Cited By ~ 25

Author(s):

CPN Watson ◽

JH Watt-Watson ◽

ML Chipman

Keyword(s):

Pain Relief ◽

Adverse Events ◽

Demographic Data ◽

Chemical Dependency ◽

Opioid Therapy ◽

Chronic Noncancer Pain ◽

History Of ◽

One Year ◽

Noncancer Pain

OBJECTIVE:To report on a long term experience in treating patients with chronic noncancer pain (CNCP).METHODS:One hundred two patients with CNCP were seen every three months and followed for one year or more (median eight years, range one to 22). Demographic data, diagnostic categories and response to therapies were recorded. The utility and safety of opioid therapy, adverse events, impact on disability and issues related to previous psychiatric or chemical dependency history were documented.RESULTS:Most patients reported a variety of neuropathic pain problems and most required chronic opioid therapy after the failure of other treatments. Although 44% reported being satisfied with pain relief despite adverse events, it is noteworthy that the remaining patients chose to continue therapy for the modest benefit of pain relief despite adverse events. Moreover, 54% were less disabled on opioid therapy.CONCLUSIONS:This is a large sample of CNCP patients, most taking opioids over a long period of time. CNCP can be treated by opioids safely and with a modest effect, with improvement in functioning in some patients who are refractory to other measures. If care is taken, opioids may even be used effectively for patients with a history of chemical dependency.

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Effectiveness of Long-Term Opioid Therapy for Chronic Non-Cancer Pain

January 2018 - Pain Physician ◽

10.36076/ppj.2011/14/e133 ◽

2011 ◽

Vol 3;14 (2;3) ◽

pp. E133-E156 ◽

Cited By ~ 3

Author(s):

Laxmaiah Manchikanti

Keyword(s):

Pain Relief ◽

Adverse Effects ◽

Cancer Pain ◽

Functional Status ◽

Outcome Measures ◽

Opioid Therapy ◽

Review Of The Literature ◽

Chronic Opioid Therapy ◽

Comprehensive Review

Background: Opioids have been utilized for thousands of years to treat pain and their use continues to escalate. It is estimated that 90% of the patients who present to pain centers and receive treatment in such facilities are on opioids. However, in contrast to increasing opioid use and the lack of evidence supporting long-term effectiveness in chronic non-cancer pain, is the escalating misuse of prescription opioids, including abuse and diversion. There is also uncertainty about the incidence and clinical salience of multiple, poorly characterized adverse drug events, including endocrine dysfunction, immunosuppression, infectious disease, opioidinduced hyperalgesia, overdoses, deaths, and psychosocial and economic implications. Study Design: A comprehensive review of the literature. Objective: The objective of this comprehensive review is to evaluate the clinical effectiveness and safety of chronic opioid therapy in chronic non-cancer pain. Methods: A comprehensive review of the literature relating to chronic opioid therapy in chronic non-cancer pain. The literature was collected from various electronic and other sources. The literature that was evaluated included randomized trials, observational studies, case reports, systematic reviews, and guidelines. Outcome Measures: Pain relief was the primary outcome measure. The secondary outcome measures were functional improvement and adverse effects. Short-term effectiveness was considered to be less than 6 months; long-term effectiveness was considered to be at least one year. Results: Given the complexity and widespread nature of opioid therapy, there is a paucity of qualitative and/or quantitative literature. The available evidence is weak for pain relief combined with improvement in functional status. Only one drug, tramadol, is effective for pain relief and improvement of functional status. Limitations: This is a narrative review without application of methodologic quality assessment criteria. Even so, a paucity of literature exists concerning both controlled and observational literature for multiple drugs and multiple conditions of chronic non-cancer pain. Conclusions: This comprehensive review illustrates the lack of literature on long-term opioid therapy; thus, opioid therapy should be provided with great restraint and caution, based on the weak evidence available. Key words: Chronic non-cancer pain, opioids, opioid effectiveness, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, methadone, oxycodone

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EVALUATION OF SHORT AND LONG TERM BENEFITS/SIDE EFFECTS OF CEMENT AUGMENTATION IN PATIENTS WITH NON INFECTIVE PATHOLOGICAL OSTEOPOROTIC VERTEBRAL COMPRESSION FRACTURES

10.36106/ijsr/4301540 ◽

2020 ◽

pp. 44-48

Author(s):

Abhay Singh ◽

Rahul Gupta ◽

Shachi Shachi

Keyword(s):

Quality Of Life ◽

Side Effects ◽

Pain Relief ◽

Vertebral Compression Fracture ◽

Compression Fracture ◽

Cement Augmentation ◽

Vertebral Compression Fractures ◽

Hybrid Technique

BACKGROUND: Vertebral compression fracture usually occurs in old age population with osteoporosis. Due to severity of pain, quality of life becomes very poor. During the study period 67 patients fullling the eligibility cri METHODS: teria underwent vertebroplasty/ kyphoplasty/ cement augmented screw xation/ hybrid procedures were included. Short term and long term benets /side effects were evaluated in all patients. Patients were evaluated on visual analogue score and modied ranking scale. RESULTS: Vertebroplasty was performed in 26(38.8%) whereas kyphoplasty, cement augmented screw xation and hybrid procedure were performed in 18(26.8%), 17(25.4%) and 6(9.0%) respectively. Signicant pain relief occurred in all patients which were evaluated by Visual Analogue Scale. Quality of life also improved which was evaluated with Modied Rankin Scale. In our study, complications which occurred were local cement leak, hematoma formation, infection in 8 (11.9%), 3(4.5%) and 2(3.0%) patients respectively. Use of biological cement has revolutionized CONCLUSION: the management of vertebral compression fracture. Both vertebroplasty and kyphoplasty procedures which are minimal invasive, almost cure the non infective pathological fractures with instant pain relief and very low procedure related morbidity. In cases requiring xation, cement augmentation signicantly improves the purchase of the screw and makes the construct more reliable. Hybrid technique helps to prevent extensive long level xation.

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