scholarly journals Chronic Opioid Therapy for Chronic Non-Cancer Pain: A Review and Comparison of Treatment Guidelines

2014 ◽  
Vol 5;17 (5;9) ◽  
pp. 401-414
Author(s):  
Chi-Wai Cheung
Keyword(s):  
Chronic Pain ◽  
Adverse Effects ◽  
Cancer Pain ◽  
Practice Guidelines ◽  
Scientific Evidence ◽  
Opioid Therapy ◽  
Scientific Data ◽  
Drug Misuse ◽  
Opioid Use ◽  
Chronic Opioid Therapy

Background: Long-term opioid use for chronic non-cancer pain has increased substantially in recent years despite the paucity of strong supporting scientific data and concerns regarding adverse effects and potential misuse. Study Design: Review and summary of practice guidelines available on PubMed and Cochrane databases as well as on the Internet on chronic opioid therapy from June 2004 to June 2013. Objective: To review expert-developed practice guidelines on chronic opioid therapy, published in different countries over the past decade in order to reveal similar principles of therapy and to provide useful information and references for future development of opioid guidelines to identify adequately supported practice points and areas in need of further scientific evidence. Method: Seven guidelines were identified as pertaining specifically to the long-term use of opioids for general chronic non-cancer pain from an initial search of the PubMed/Medline and Cochrane databases using combinations of the search terms “opioid,” “chronic opioid therapy,” “chronic pain,” “chronic non-cancer pain,” “chronic non-malignant pain,” “guidelines,” “practice guidelines,” and “clinical practice guidelines,” filtered to include only articles on humans published in the English language over the past 10 years. Results: All guidelines espouse an individual approach to management, beginning with a comprehensive patient evaluation, with particular focus on eliciting factors that may indicate potential drug misuse and abuse, and a trial of therapy to determine the course of treatment. Goals of treatment should be adequately discussed with and consented to by the patient. Opioids are generally not recommended as first-line therapy but, when used, clinicians should closely monitor patients for loss of response, adverse effects or aberrant behavior, and revise the treatment plan accordingly. Urine drug testing (UDT) may be used as a tool to monitor for aberrant behavior or drug misuse; opioid rotation may be considered when loss of response or adverse effects are a concern, at a starting dose lower than the calculated equianalgesic dose. Limitations: Information on some African nations, countries in the Middle-East, and Pacific Islands is not available and therefore was not included in this review. Conclusion: There is a growing body of scientific evidence to support opioid use in chronic pain. Future work should focus on continuing to generate good-quality evidence on the longterm benefits of opioid therapy, as well as scientific data to guide drug choice and dosing for specific conditions, populations, and situations. Key words: Chronic pain, opioid, non-cancer pain, guidelines, opioid rotation, pain management, opioid therapy

Adverse effects and cognitive function among primary care patients taking opioids for chronic nonmalignant pain

2006 ◽  
Vol 2 (3) ◽  
pp. 137 ◽  
Author(s):  
Randall T. Brown, MD ◽  
Megan Zuelsdorff, BS ◽  
Michael Fleming, MD, MPH
Keyword(s):  
Mental Health ◽  
Primary Care ◽  
Chronic Pain ◽  
Cognitive Function ◽  
Adverse Effects ◽  
Primary Care Physicians ◽  
Opioid Therapy ◽  
Chronic Opioid Therapy ◽  
Nonmalignant Pain ◽  
Chronic Nonmalignant Pain

Chronic opioid therapy is commonly prescribed for chronic nonmalignant pain. Few published data describe the adverse effects experienced by patients with chronic nonmalignant pain being treated by primary care physicians. A prevalence study was conducted on a sample of 1,009 patients (889 receiving chronic opioids) being treated by 235 primary care physicians. Standardized questionnaires and medical record reviews were used to assess rates of addiction, pain diagnosis and severity, opioid adverse effects, and mental health. The mean daily dose of opioids was 92 mg using a morphine-equivalent conversion. Side effects included constipation (40 percent), sleeping problems (25 percent), loss of appetite (23 percent), and sexual dysfunction (18 percent), with patients on daily opioids experiencing more side effects than subjects on intermittent medication. The Medical Outcomes Study Mental Health Inventory (MOS-MHI) cognitive functioning scale indicated poorer cognitive function in the overall sample of chronic pain patients as compared to a general clinical sample (Δ x 95 percent CI = 9.28, 13.76). However, there were limited differences in MOS scores between chronic pain subjects on daily opioids vs. intermittent opioids vs. no prescription opioids. A regression model suggests that psychological measures and pain severity are more predictive of decrements in cognitive function than specific opioid preparations or daily opioid dose. Physicians should closely monitor patients for adverse effects and adequacy of pain control when using chronic opioid therapy for chronic pain treatment. Psychological health, an important predictor of cognitive dysfunction, is a particularly important measure to actively monitor and manage.

scholarly journals Urine Drug Testing In Chronic Pain

2011 ◽  
Vol 3;14 (2;3) ◽  
pp. 123-143 ◽  
Author(s):  
Paul J. Christo
Keyword(s):  
Chronic Pain ◽  
Prescription Drugs ◽  
Drug Testing ◽  
Opioid Therapy ◽  
Drug Misuse ◽  
Compliance Monitoring ◽  
Chronic Opioid Therapy ◽  
Urine Drug Testing ◽  
Urine Drug ◽  
Adherence Monitoring

Therapeutic use, overuse, abuse, and diversion of controlled substances in managing chronic non-cancer pain continue to be an issue for physicians and patients. The challenge is to eliminate or significantly curtail abuse of controlled prescription drugs while still assuring the proper treatment of those patients. Some physicians are apprehensive regarding the use of chronic opioid therapy in chronic non-cancer pain due to a perceived lack of proven evidence, the misuse of opioids, tolerance, dependence, and hyperalgesia. However, others have criticized the underuse of opioids, resulting in the undertreatment of pain. It has been the convention that federal, state, and local governments; professional associations; as well as pharmaceutical companies, physicians, accrediting bodies, medical licensure boards, and the public all share responsibility for preventing abuse of controlled prescription drugs. To overcome the critical challenge of eliminating or significantly curtailing abuse of controlled prescription drugs and at the same time assuring the appropriate treatment for those patients who can be helped by these medications, it is crucial to practice adherence or compliance monitoring of opioid therapy. Compliance monitoring has been shown to be crucial in delivering proper opioid therapy and preserving this therapy for the future. Urine drug testing (UDT) is considered one of the mainstays of adherence monitoring in conjunction with prescription monitoring programs and other screening tools, however, UDT is associated with multiple limitations secondary to potential pitfalls related to drug metabolism, reliability of the tests, and the knowledge of the pain physician. UDT is a widely available and familiar method for monitoring opioid use in chronic pain patients. UDT can provide tools for tracking patient compliance and expose possible drug misuse and abuse. UDT is one of the major tools of adherence monitoring in the assessment of the patient’s predisposition to, and patterns of, drug misuse/abuse – a vital first step towards establishing and maintaining the safe and effective use of opioid analgesics in the treatment of chronic pain. This comprehensive review provides the role of UDT in monitoring chronic opioid therapy along with reliability and accuracy, appropriate use, overuse, misuse, and abuse. Key words: Controlled substances, opioids, benzodiazepines, illicit drugs, abuse, diversion, prescription monitoring programs, adherence monitoring, compliance monitoring, urine drug testing, immunoassay, chromatography, false-positives, false-negatives

scholarly journals Opioids and Chronic Pain: An Analytic Review of the Clinical Evidence

2021 ◽  
Vol 2 ◽  
Author(s):  
Stephen E. Nadeau ◽  
Jeffrey K. Wu ◽  
Richard A. Lawhern
Keyword(s):  
Chronic Pain ◽  
Scientific Evidence ◽  
The United States ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Opioid Use ◽  
Opioid Treatment ◽  
Opioid Dose ◽  
Risk Of Death ◽  
Analytic Review

We conducted an analytic review of the clinical scientific literature bearing on the use of opioids for treatment of chronic non-cancer pain in the United States. There is substantial, albeit not definitive, scientific evidence of the effectiveness of opioids in treating pain and of high variability in opioid dose requirements and side effects. The estimated risk of death from opioid treatment involving doses above 100 MMED is ~0.25%/year. Multiple large studies refute the concept that short-term use of opioids to treat acute pain predisposes to development of opioid use disorder. The prevalence of opioid use disorder associated with prescription opioids is likely <3%. Morbidity, mortality, and financial costs of inadequate treatment of the 18 million Americans with moderate to severe chronic pain are high. Because of the absence of comparative effectiveness studies, there are no scientific grounds for considering alternative non-pharmacologic treatments as an adequate substitute for opioid therapy but these treatments might serve to augment opioid therapy, thereby reducing dosage. There are reasons to question the ostensible risks of co-prescription of opioids and benzodiazepines. As the causes of the opioid crisis have come into focus, it has become clear that the crisis resides predominantly in the streets and that efforts to curtail it by constraining opioid treatment in the clinic are unlikely to succeed.

scholarly journals Framing of the opioid problem in cancer pain management in Canada

2019 ◽  
Vol 26 (3) ◽  
Author(s):  
R. Asthana ◽  
S. Goodall ◽  
J. Lau ◽  
C. Zimmermann ◽  
P. L. Diaz ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Cancer Pain ◽  
Opioid Therapy ◽  
Position Paper ◽  
Chronic Pain Management ◽  
Opioid Use ◽  
Cancer Pain Management ◽  
Canadian Guideline ◽  
Patients With Cancer

Two guidelines about opioid use in chronic pain management were published in 2017: the Canadian Guideline for Opioids for Chronic Non-Cancer Pain and the European Pain Federation position paper on appropriate opioid use in chronic pain management. Though the target populations for the guidelines are the same, their recommendations differ depending on their purpose. The intent of the Canadian guideline is to reduce the incidence of serious adverse effects. Its goal was therefore to set limits on the use of opioids. In contrast, the European Pain Federation position paper is meant to promote safe and appropriate opioid use for chronic pain.     The content of the two guidelines could have unintentional consequences on other populations that receive opioid therapy for symptom management, such as patients with cancer. In this article, we present expert opinion about those chronic pain management guidelines and their impact on patients with cancer diagnoses, especially those with histories of substance use disorder and psychiatric conditions. Though some principles of chronic pain management can be extrapolated, we recommend that guidelines for cancer pain management should be developed using empirical data primarily from patients with cancer who are receiving opioid therapy.

scholarly journals Effect of Chronic Opioid Therapy on Pain and Survival in a Mouse Model of Sickle Cell Disease

Blood ◽  
2018 ◽  
Vol 132 (Supplement 1) ◽  
pp. 726-726
Author(s):  
Varun Sagi ◽  
Huy Tran ◽  
Waogwende Leonce Song-Naba ◽  
Ying WANG ◽  
Aditya M Mittal ◽  
...  
Keyword(s):  
Chronic Pain ◽  
Sickle Cell Disease ◽  
Sickle Cell ◽  
Opioid Therapy ◽  
Cell Disease ◽  
Opioid Use ◽  
Chronic Opioid Therapy ◽  
Morphine Treatment ◽  
Chronic Morphine ◽  
Pain Characteristics

Abstract Pain is one of the major comorbidities of sickle cell disease (SCD) requiring chronic opioid therapy (COT). However, COT has been associated with reduced survival and opioid-induced hyperalgesia (OIH), which can exacerbate the chronic pain and increased mortality already inherent to SCD. It is challenging to examine pain, opioid use and survival in populations with SCD due to significant heterogeneity in multiple clinicopathologic factors. To determine the effect of COT we used transgenic HbSS BERK sickle mice, which show pain characteristics similar to those observed in patients with SCD, including sensitivity to thermal and mechanical stimuli, increased opioid requirement, and higher levels of circulating substance P and tryptase (Tran et al., Blood 2017). Additionally, similar to female patients with SCD, female BERK sickle mice show more pain than males. Therefore, we performed a randomized double-blind placebo-controlled trial to examine the effect of COT on pain and survival in female homozygous HbSS BERK (sickle) and HbAA BERK (control) mice, expressing >99% human sickle hemoglobin and normal human hemoglobin A, respectively. Mice were injected subcutaneously each day with either morphine sulfate at a starting dose of 20 mg/kg, which was increased to 25 mg/kg, 30 mg/kg, 35 mg/kg, and 40 mg/kg after weeks 12, 18, 28, 30, and 38 respectively or placebo (equal volume of saline) until the end of survival. Dose of morphine was selected based on the effective analgesic dose for these mice (Kohli et al., Blood 2010). Mechanical-, thermal- (heat and cold), and musculoskeletal/deep hyperalgesia were analyzed in all mice biweekly before and after drug treatments. We used Kaplan-Meier and log-rank test with Sidak correction for survival; 2-way repeated measures analysis of variance with Bonferroni's correction to compare hyperalgesia between time points among control and sickle mice and Cox proportional-hazards regression analysis for the association of hyperalgesia with survival. We observed significantly decreased survival of saline-treated sickle mice compared to saline-treated control mice (P = 0.0009). Compared to saline, morphine treatment led to a significant decrease in survival in control mice (P = 0.035) but not in sickle mice (P > 0.05). Furthermore, we did not observe an association between hyperalgesia and survival in either control or sickle mice. However, we discerned a significant increase in mechanical, cold, and heat hyperalgesia in control mice after 4 weeks of morphine treatment (P < 0.02, compared to day '0') which continued to increase up to 12 weeks (P <0.05 compared to week 4). Similarly, in sickle mice we observed an increase in mechanical hyperalgesia after 4 weeks (P <0.02, compared to day '0') of morphine treatment which continued to increase up to 12 weeks (P < 0.0001). These data suggest COT leads to OIH in both control and sickle mice. It is noteworthy that morphine treatment continued to show an analgesic effect over the course of 12 weeks in spite of an increase in hyperalgesia in both groups of mice. Thus, mice did not develop tolerance to morphine analgesia. Since mice were treated under uniform conditions, the effect of chronic morphine treatment could be observed without any confounding factors. Our findings in control mice recapitulate the clinical observations that COT is associated with reduced lifespan in non-sickle patients. COT lead to OIH in sickle mice but provided analgesia without causing tolerance or reducing survival. OIH may contribute may exacerbate a vicious cycle of chronic pain and opioid use in SCD. Differences exist between humans and mice including morphine metabolism between the two but due to several similarities of HbSS BERK sickle mice with clinical pain characteristics and biology, these observations have a significant translational potential following clinical trials for optimizing the treatment of pain in SCD. These data highlight the critical need to develop analgesic strategies devoid of OIH. Disclosures Gupta: Tau tona: Consultancy; Novartis: Honoraria.

scholarly journals Chronic pain management and the development of opioid use disorder

2018 ◽  
Vol 87 (1) ◽  
pp. 55-57
Author(s):  
Lily Robinson ◽  
Richard Yu ◽  
Salonee Patel
Keyword(s):  
Chronic Pain ◽  
Pain Management ◽  
Cancer Pain ◽  
Medical Management ◽  
Opioid Therapy ◽  
Opioid Use Disorder ◽  
Medical Attention ◽  
Prescription Opioid ◽  
Evidence Based ◽  
Opioid Use

Chronic pain is a common condition that impacts quality of life and often precipitates the need for medical attention. Despite evidence that long-term opioid use provides limited relief, prescription opioid therapy remains a cornerstone in the medical management of chronic non-cancer pain. Presently, 13% of Canadians are prescribed opioids for pain management, and physicians play a crucial role in preventing the development of opioid use disorders. However, Canadian physicians lack knowledge of and comfort with evidence-based principles of opioid stewardship. In this article, we aim to highlight ongoing Canadian efforts to address physician discomfort and improve clinical practice. We focus on 2017 Canadian guidelines that provide clinicians with evidence-based recommendations for opioid use in chronic non-cancer pain management. In addition, we call attention to provincial efforts to implement physician accountability measures. In reviewing the existing literature, we uncovered inadequacies in pain management curricula within the Canadian undergraduate and continuing medical education (CME) systems. We consulted the educational practices of the European Pain Federation and the Centers for Disease Control and Prevention to make recommendations for improvement to current Canadian pain curricula. Based on our findings, we recommend that (1) Canadian medical institutions expand upon current core pain curricula, (2) pain management education be made compulsory, (3) academic detailing be emphasized as a means of CME, and (4) multidisciplinary non-medical management of chronic pain be featured more extensively.

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

2011 ◽  
Vol 3;14 (2;3) ◽  
pp. E133-E156 ◽  
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

scholarly journals Predictors of Chronic Opioid Use: A Population-level Analysis of North Carolina Cancer Survivors Using Multi-Payer Claims

2021 ◽  
Author(s):  
Devon K Check ◽  
Christopher D Bagett ◽  
KyungSu Kim ◽  
Andrew W Roberts ◽  
Megan C Roberts ◽  
...  
Keyword(s):  
North Carolina ◽  
Substance Use ◽  
Cancer Survivors ◽  
Low Income ◽  
Opioid Therapy ◽  
Adjusted Relative Risk ◽  
Opioid Use ◽  
Chronic Opioid Therapy ◽  
Increased Risk ◽  
Chronic Opioid Use

Abstract Background No population-based studies have examined chronic opioid use among cancer survivors who are diverse with respect to diagnosis, age group, and insurance status. Methods We conducted a retrospective cohort study using North Carolina (NC) cancer registry data linked with claims from public and private insurance (2006–2016). We included adults with non-metastatic cancer who had no prior chronic opioid use (N = 38,366). We used modified Poisson regression to assess the adjusted relative risk of chronic opioid use in survivorship (&gt;90-day continuous supply of opioids in the 13–24 months following diagnosis) associated with patient characteristics. Results Only 3.0% of cancer survivors in our cohort used opioids chronically in survivorship. Predictors included younger age (adjusted risk ratio [aRR], 50–59 vs 60–69 = 1.23, 95% confidence interval [CI] = 1.05–1.43), baseline depression (aRR = 1.22, 95% CI = 1.06–1.41) or substance use (aRR = 1.43, 95% CI = 1.15–1.78) and Medicaid (aRR vs Private = 1.93, 95% CI = 1.56–2.40). Survivors who used opioids intermittently (vs not at all) before diagnosis were twice as likely to use opioids chronically in early survivorship (aRR = 2.62, 95% CI = 2.28–3.02). Those who used opioids chronically (vs intermittently or not at all) during active treatment had a nearly 17-fold increased likelihood of chronic use in survivorship (aRR = 16.65, 95 CI = 14.30–19.40). Conclusions Younger and low-income survivors, those with baseline depression or substance use, and those who require chronic opioid therapy during treatment are at increased risk for chronic opioid use in survivorship. Our findings point to opportunities improve assessment of psychosocial histories and to engage patients in shared decision-making around long-term pain management, when chronic opioid therapy is required during treatment.

scholarly journals Problems and concerns of patients receiving chronic opioid therapy for chronic non-cancer pain

Pain ◽  
2010 ◽  
Vol 149 (2) ◽  
pp. 345-353 ◽  
Author(s):  
Mark D. Sullivan ◽  
Michael Von Korff ◽  
Caleb Banta-Green ◽  
Joseph O. Merrill ◽  
Kathleen Saunders
Keyword(s):  
Cancer Pain ◽  
Opioid Therapy ◽  
Chronic Opioid Therapy
Sign in / Sign up

Export Citation Format

Share Document