The endocrine effects of long-term oral opioid therapy: A case report and review of the literature

2018 ◽  
Vol 7 (2) ◽  
pp. 145-154 ◽  
Author(s):  
Jennifer A. Elliott, MD ◽  
Erica Horton, DO ◽  
Eugene E. Fibuch, MD
Keyword(s):  
Case Report ◽  
Endocrine System ◽  
The United States ◽  
Opioid Therapy ◽  
Chronic Opioid Therapy ◽  
Negative Effects ◽  
Opioid Administration ◽  
Nonmalignant Pain ◽  
Chronic Nonmalignant Pain

The negative effects of long-term opioid administration on the body’s endocrine system have been known for decades.1,2 These effects have been observed and studied with the use of intrathecal opioids and in heroin addicts.3-9 However, they have also been noted to occur with the use of oral opioids, especially in those patients who require chronic opioids for the management of nonmalignant and cancer-associated pain.2,10-13 Epidemiologic data in recent years suggest that up to five million men with chronic nonmalignant pain suffer from opioid-induced androgen deficiency (OPIAD) in the United States.14 Therefore, it is important to understand the physiologic impact of chronic opioid administration in patients. In view of the increasing use of opioids for chronic pain, we must anticipate the potential occurrence of hypogonadism during chronic opioid therapy and monitor patients accordingly. If symptoms of endocrine dysfunction are recognized during chronic opioid therapy, appropriate evaluation, treatment, and follow-up should be instituted. This article describes a case report of a patient who suffered from a clinically significant testosterone deficiency and osteoporosis related to the use of long-term oral opioids for chronic nonmalignant pain. It also includes a review of the existing literature regarding OPIAD and provides recommendations regarding the evaluation and management of OPIAD.

scholarly journals Androgen Deficiency in Long-Term Intrathecal Opioid Administration

2014 ◽  
Vol 4;17 (4;7) ◽  
pp. E543-E548
Author(s):  
Chong H. Kim
Keyword(s):  
Drug Delivery ◽  
Case Series ◽  
Androgen Deficiency ◽  
Endocrine Dysfunction ◽  
Intrathecal Drug Delivery ◽  
Opioid Administration ◽  
Nonmalignant Pain ◽  
Chronic Nonmalignant Pain ◽  
Intrathecal Opioid Administration

Background: Intrathecal drug delivery of opioids is an efficient and effective treatment option for pain management in the chronic nonmalignant pain population. As with all treatments, in addition to the benefits, risks and side effects exist. One such risk in intrathecal opioids is opioid-induced androgen deficiency. Objective: This study evaluates opioid-induced androgen deficiency in long-term intrathecal opioid administration in chronic nonmalignant pain. Study Design: Case series. Sixteen consecutive patients with intrathecal drug delivery with opioids were screened for androgen deficiency. Setting: Academic university-based pain management center. Method: All the subjects were seen in a 2 month period, during a scheduled maintenance refill visit. Eight consecutive men and eight consecutive women receiving intrathecal drug delivery therapy for non-malignant chronic pain were ordered blood work and asked to complete a questionnaire. Patient and patient-related data were also collected. Results: Ten of the 16 (62.5%) patients were found to have androgen deficiency, 4 of 8 men based on free testosterone levels and 6 of 8 women based on DHEA levels. In men, erectile dysfunction correlated with endocrine dysfunction (P = 0.02) while depressive symptoms correlated in women (P = .03). Overall, 2 of the 16 patients had hydromorphone as the opioid in the intrathecal system. Both patients had normal endocrine functions. Both patients with hydromorphone were men and the use of hydromorphone showed an insignificant trend (P = 0.06). Three of the 4 men with normal endocrine functions had in addition to an opioid, bupivacaine, in the intrathecal system. The presence of bupivicaine in men was significant (P = 0.02). No women had bupivicaine while one of the 8 women had clonidine in addition to the opioid. Presence of another substance in addition to the opioid showed an insignificant trend (P = 0.08). Limitations: Study limitations include the small sample size and case series nature. Additionally the symptoms data was solely based on subjective patient reports. Conclusions: Androgen deficiency is common in patients treated with intrathecal opioids for chronic nonmalignant pain. Patients experience numerous and wide ranging symptoms. Erectile dysfunction may be more suggestive for androgen deficiency in men while complaints of depressed mood may be correlative in women. Additionally, combining bupivicaine with the intrathecal opioid may provide a protective role. Key words: Androgen deficiency, endocrine dysfunction, chronic nonmalignant pain, intrathecal opioid, intrathecal drug delivery, side effects

Opioid Therapy for Chronic Nonmalignant Pain: Clinicians' Perspective

1996 ◽  
Vol 24 (4) ◽  
pp. 296-309 ◽  
Author(s):  
Russell K. Portenoy
Keyword(s):  
Psychosocial Functioning ◽  
Cumulative Risk ◽  
Opioid Therapy ◽  
Adverse Outcomes ◽  
The Public ◽  
The Past ◽  
Nonmalignant Pain ◽  
Chronic Nonmalignant Pain

During the past decade, debate has intensified about the role of long-term opioid therapy in the management of chronic nonmalignant pain. Specialists in pain management have discussed the issues extensively and now generally agree that a selected population of patients with chronic pain can attain sustained analgesia without significant adverse consequences. This perspective, however, is not uniformly accepted by pain specialists and has not been widely disseminated to other disciplines or the public. Rather, the more traditional perspective, which ascribes both transitory benefit and substantial cumulative risk to long-term opioid therapy, continues to predominate. According to this perspective, the inevitability of tolerance limits the possibility of sustained efficacy, and other pharmacological properties increase the likelihood of adverse outcomes, including persistent side-effects, impairment in physical and psychosocial functioning, and addiction. If accurate, these outcomes would indeed justify the withholding of opioid therapy for all but the most extreme cases of chronic nonmalignant pain.

Functional Outcomes in Patients with Chronic Nonmalignant Pain on Long-Term Opioid Therapy

Pain Practice ◽  
2008 ◽  
Vol 8 (5) ◽  
pp. 379-384 ◽  
Author(s):  
Amol Soin ◽  
Jianguo Cheng ◽  
Lora Brown ◽  
Sami Moufawad ◽  
Nagy Mekhail
Keyword(s):  
Functional Outcomes ◽  
Opioid Therapy ◽  
Nonmalignant Pain ◽  
Chronic Nonmalignant Pain

scholarly journals Chronic Use of Opioids for Nonmalignant pain: A Prospective Study

1997 ◽  
Vol 2 (2) ◽  
pp. 101-107 ◽  
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.

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 Opioid Therapy for Chronic Nonmalignant Pain

1996 ◽  
Vol 1 (1) ◽  
pp. 17-28 ◽  
Author(s):  
Russell K Portenoy
Keyword(s):  
Chronic Pain ◽  
Opioid Therapy ◽  
Minimal Risk ◽  
Addiction Medicine ◽  
Nonmalignant Pain ◽  
Term Administration ◽  
Chronic Nonmalignant Pain ◽  
Physician Prescribing ◽  
Structured Approach

Long term administration of an opioid drug for chronic nonmalignant pain continues to be controversial, but is no longer uniformly rejected by pain specialists. This is true despite concerns that the regulatory agencies that oversee physician prescribing of opioid drugs continue to stigmatize the practice. The changing clinical perspective has been driven, in part, by widespread acknowledgement of the remarkably favourable outcomes achieved during opioid treatment of cancer pain. These outcomes contrast starkly with popular teaching about chronic opioid therapy and affirm the potential for prolonged efficacy, tolerable side effects, enhanced function associated with improved comfort and minimal risk of aberrant drug-related behaviours consistent with addiction. A large anecdotal experience in populations with nonmalignant pain suggests that these patients are more heterogeneous and that opioid therapy will greatly benefit some and will contribute to negative outcomes for others. The few controlled clinical trials that have been performed support the safety and efficacy of opioid therapy, but have been too limited to ensure generalization to the clinical setting. A critical review of the medical literature pertaining to chronic pain, opioid pharmacology and addiction medicine can clarify misconceptions about opioid therapy and provide a foundation for patient selection and drug administration. The available data support the view that opioids are no panacea for chronic pain, but should be considered in carefully selected patients using clinically derived guidelines that stress a structured approach and ongoing monitoring of efficacy, adverse effects, functional outcomes and the occurrence of aberrant drug-related behaviours.

561 Bilateral Upper Extremity Amputation After High Voltage Electrical Injury: A Case Report

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S130-S131
Author(s):  
Andrew Khalifa ◽  
Anzar Sarfraz ◽  
Jacob B Avraham ◽  
Ronnie Archie ◽  
Matthew Kaminsky ◽  
...  
Keyword(s):  
Case Report ◽  
High Voltage ◽  
Troponin I ◽  
Low Voltage ◽  
Foley Catheter ◽  
The United States ◽  
Upper Extremities ◽  
Full Thickness ◽  
Electrical Injuries

Abstract Introduction Electrical injuries represent 0.4–3.2% of admissions to burn units and are responsible for >500 deaths per year in the United States. Approximately half occur in the workplace and are the fourth leading cause of work-related-traumatic death. The extent of injury can be drastically underestimated by total body surface area percentage (TBSA). Along with cutaneous burns, high voltage electrical injuries can lead to necrosis of muscle, bone, nervous tissue, and blood vessels. Aggressive management allows for patient survival, but at significant cost. Newer technologic advances help improve functional outcomes. Methods This case-report was conducted via retrospective chart review of the case presented. Results A 43-year-old male sustained a HVEI (>10, 000 V) after contacting an active wire while working as a linesman for an electric company. He presented after less than 15-minute transport from an outside hospital with full thickness burns and auto-amputation to all fingers on both hands and the distal third of the left hand (Images 1 and 2). There were full thickness circumferential burns to the entire left and right upper extremities with contractures, with the burns extending into the axilla, and chest wall musculature. The patient had 4th degree burns and a large wound to the left shoulder with posterior extension to the scapula, flank and back with approximately 25% TBSA (Image 3). Compartments were tense in both upper extremities. Patient was sedated and intubated to protect the airway and placed on mechanical ventilation. A femoral central line was then placed, and the patient was given pain control, continued fluid resuscitation, and blood products. Dark red colored urine from a foley catheter that was immediately identified as rhabdomyolysis induced myoglobinuria. Labs drawn demonstrated elevated troponin I, CK >40,000. BUN 18, creatinine 1.0, K+ 5.2 and phosphate 5.6. Decision was made immediately for operative intervention with emergent amputation of both upper extremities in the light of rhabdomyolysis secondary to tissue necrosis and oliguria. During the patient’s hospital course, he underwent multiple operations for further debridement with vacuum-assisted closure therapy and skin grafting of sites, as well as targeted muscle reinnervation (TMR) 6 months later at an outside hospital. Conclusions Although HVEI only account for a small percentage of burn admissions, they are associated with greater morbidity than low-voltage injuries. Patients with HVEI often incur multiple injuries, more surgical procedures, have higher rates of complications, and more long term psychological and rehabilitative difficulties. Despite the need for amputation in some of these critically ill patients, options exist that allow for them to obtain long term functional success.

Sign in / Sign up

Export Citation Format

Share Document