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The Appropriate Use of Opiates in Chronic Pain

Autry J. Parker, MD, MPH

Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee

Pain acts as a warning signal of illness or tissue damage and aids in diagnosing the underlying cause. However, once the illness or damage has been identified, pain no longer serves a function. Pain should then be addressed separately from the underlying diagnosis—ie, the patient’s condition does not need to be cured for the pain to resolve. Chronic pain is pain that continues after the usual healing time, which is generally considered to be 3 months,1 and moderate-to-severe noncancer-related chronic pain affects about 15% of the adult US population (AV 1).2 Although opioids are effective for treating many forms of chronic pain, too often pain goes undertreated because of safety concerns with these medications.

AV 1. Adults Reporting Pain and the Chronicity of That Pain (0:30)

AV 1. Algorithm for the Diagnosis of Pain in Patients With MS
Opioid Treatment of Chronic Pain

Opiates and synthetic opioids are the most potent analgesics available to treat moderate-to-severe pain and are widely prescribed for both cancer- and noncancer-related pain.3 Opioids are available in a variety of drug delivery methods, such as intraspinal, intravenous, transmucosal, transdermal, and oral; each delivery system has advantages in certain situations. Intraspinal delivery should be managed by specialists and is not discussed in this article.

Intravenous opioids have a rapid onset of action and are used in the hospital setting to relieve acute and severe pain from surgery or injury. Transmucosal administration also has a fast onset of analgesia and is effective for acute pain as well as for breakthrough pain during the treatment of chronic pain. This method of delivery can be useful for patients who have trouble swallowing oral medication.

With transdermal opioid administration, the medication is released slowly from a skin patch and is absorbed into the fat tissue below the skin, providing long-lasting pain relief. Transdermal patches are appropriate for patients with a steady level of chronic pain because the dosage cannot be adjusted quickly in the event that the patient’s level of pain increases.

Oral opioids are the most common form of pain treatment and are broadly categorized as short- or long-acting. Short-acting medications have a rapid onset of effect, but due to their brief duration of action may need to be taken every 4 to 6 hours. Long-acting medications have a longer time to analgesic onset, but may last up to 24 hours. A combination of both short- and long-acting medications may be used for patients with sustained levels of pain who also experience breakthrough pain.

When initiating an opioid trial for a patient with chronic pain, treatment selection and titration should be based on the patient’s health status, treatment history, treatment goals, and risk for adverse effects. After starting opioid treatment, patients should be monitored for common adverse effects, including constipation, nausea, sedation, and cognitive dysfunction. Because opioids can also suppress respiration, caution should be used when combining them with other sedative drugs or when prescribing them for patients with conditions such as congestive heart failure, COPD, sleep apnea, and excretion or metabolic difficulties such as renal or hepatic dysfunction.

Mitigating the Risks of Opioid Addiction and Misuse/Abuse

Although opioids are an indispensable tool for treating pain, they must be used with care due to the risks for overdose and addiction. The dramatic increase in the prescription of opioids for pain over the last 2 decades has been paralleled by an increase in deaths from overdoses and accidental poisonings (AV 2).4 Deaths due to unintended opioid overdose now outnumber deaths due to both cocaine and heroine overdose combined.

AV 2. Opioid Sales and Unintentional Opioid Overdose Deaths (0:41)

AV 2. MS-Related Pain Syndromes and Recommended Treatments

Misusing or abusing opioids can also lead to addiction, and acquiring the medication can become the patient’s only goal. Therefore, risk assessment for substance abuse, misuse, and addiction is a crucial component of chronic pain treatment.

To properly assess patients’ risk, physicians should understand that addiction is different from dependence or tolerance.5 Addiction is characterized by craving and the compulsive use of a drug that produces dysfunction, the inability to control this use, and the continued use despite physical, mental, or social harm. Dependence is the physiologic process in which withdrawal symptoms occur when the medication is stopped or the dosage is rapidly decreased. Most patients who are placed on long-term opioid therapy become dependent. Tolerance means that prolonged exposure to the medication reduces its effect and more of the drug is needed to obtain the same effect. When stopping opioid treatment, carefully tapering the drug can prevent withdrawal symptoms associated with dependence. Using long-acting medications, which maintain a constant plasma-level concentration of the opioid, may reduce the risk of addiction, lessen withdrawal symptoms between doses, and decrease opioid-induced euphoria.6

Risk assessment for opioid addiction and misuse/abuse should include a thorough patient history, a physical examination, and appropriate diagnostic testing. A personal or family history of alcohol or drug abuse is the strongest predictive factor for opioid abuse or misuse; comorbid depression and a history of preadolescent sexual abuse are also associated with an increased risk for aberrant opioid-related behaviors.1,7 Questionnaires designed to help screen patients for opioid abuse risk prior to initiating treatment include the ORT, DIRE, SOAPP-R, and SISAP.

Restoring function is the goal of treatment, and most patients will find a stable dose that balances pain relief with increased function. However, some forms of pain are not responsive to opioids; therefore, opioid treatment would not return the patient to a normal level of function but might, over time, compound the patient’s dysfunction with addiction. Patients should be carefully monitored for both improved function and addiction over the course of treatment. Tools that monitor function include the FPS and the Pain and Activity Tracking Log. The ABC, COMM, and PDUQ are tools that screen for current aberrant behaviors that may indicate addiction in patients taking long-term opioid therapy.

Addicted patients with chronic pain represent a particular challenge to the physician. Because a patient’s pain cannot be objectively confirmed, physicians have to rely on patient report; therefore, physicians should learn to recognize drug-seeking behaviors.8 For instance, an addicted patient may claim to have severe pain while also reporting suspicious allergies or side effects to any treatments that are not the patient’s drug of choice. Other drug-seeking behaviors include obtaining prescriptions from multiple sources (ie, doctor shopping), altering prescriptions to raise the dose without physician authorization, abusing illicit substances, and exhibiting deterioration of function at work or at home. Certain drug-seeking behaviors, however—eg, occasionally taking more medication than prescribed and thus running out of medication early—may be the result of undertreatment and will resolve with adequate treatment of the patient’s pain.

Patients should be fully informed of the risks and benefits of opioid treatment. Once informed consent has been obtained from the patient, a written treatment plan with stated objectives should be implemented and periodically reviewed.5 Sometimes formal opioid agreements, in which the patient agrees to certain conditions to lessen the risk of misuse or abuse, can be helpful. If deemed necessary, physicians can monitor their patients’ drug consumption through pill counts and pharmacy checks and through unannounced urine or serum toxicology screens.

Conclusion

Chronic pain is a common but undertreated health problem. Opioids are recommended for treating chronic pain, but must be used with care. When initiating opioid treatment, physicians should perform a thorough patient history, physical exam, and appropriate testing and also assess the patient’s risk for substance misuse, abuse, or addiction. Patients should be monitored regularly for both improvement of function and for aberrant drug behaviors, and treatment regimens should be adjusted accordingly. With proper monitoring and risk management, patients with chronic pain can be treated safely and effectively with opioids.

For Clinical Use
  • Be aware that chronic pain is a common but undertreated health problem
  • Understand the safety and risk management obligations of using opioids in treating chronic pain
  • Routinely use tools to assess patients for opioid abuse and abuse risk
  • Monitor patients for improved function and for aberrant drug behaviors throughout opioid treatment
Abbreviations

ABC = Addiction Behaviors Checklist; COMM = Current Opioid Misuse Measure; COPD = chronic obstructive pulmonary disease; DIRE = Diagnosis, Intractability, Risk, Efficacy; FPS= Functional Pain Scale; ORT = Opioid Risk Tool; PDUQ = Prescription Drug Use Questionnaire; SISAP = Screening Instrument for Substance Abuse Potential; SOAPP-R = Screener and Opioid Assessment for Patients with Pain-Revised

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References
  1. Chou R, Fanciullo GJ, Fine PG, et al, for the American Pain Society and the American Academy of Pain Medicine Opioids Guidelines Panel. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–130. PubMed
  2. National Center for Health Statistics. Health, United States, 2006. Hyattsville, MD: Centers for Disease Control and Prevention, US Dept of Health and Human Services; 2006. http://www.cdc.gov/nchs/data/hus/hus06.pdf. Accessed January 4, 2012.
  3. Furlan AD, Sandoval JA, Mailis-Gagnon A, et al. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589–1594. PubMed
  4. Paulozzi LJ, Weisler RH, Patkar AA. A national epidemic of unintentional prescription opioid overdose deaths: how physicians can help control it. J Clin Psychiatry. 2011;72(5):589–592. Abstract
  5. Savage S, Covington EC, Heit HA, et al, for the American Academy of Pain, the American Pain Society, and the American Society of Addiction Medicine. Definitions related to the use of opioids for the treatment of pain. Published 2001. http://www.erowid.org/psychoactives/addiction/addiction_definitions1.pdf. Accessed January 4, 2012.
  6. Adriaensen H, Vissers K, Noorduin H, et al. Opioid tolerance and dependence: an inevitable consequence of chronic treatment? Acta Anaesthesiol Belg. 2003;54(1):37–47. PubMed
  7. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–442. PubMed
  8. Højsted J, Sjøgren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain. 2007;11(5):490–518. PubMed
From the Series:
The Appropriate Use of Opiates in Chronic Pain

Independently developed by the CME Institute of Physicians Postgraduate Press, Inc.

CME Background Information

Independently developed by the CME Institute of Physicians Postgraduate Press, Inc.

Objective

After completing this educational activity, you should be able to:

  • Select the most appropriate intervention for a patient experiencing chronic pain

Financial Disclosure

The faculty for this CME activity and the CME Institute staff were asked to complete a statement regarding all relevant personal and financial relationships between themselves or their spouse/partner and any commercial interest. The CME Institute has resolved any conflicts of interest that were identified. No member of the CME Institute staff reported any relevant personal financial relationships. Faculty financial disclosure is as follows:

Dr Parker has no personal affiliations or financial relationships with any commercial interest to disclose relative to the activity.

Accreditation Statement

The CME Institute of Physicians Postgraduate Press, Inc., is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation

The CME Institute of Physicians Postgraduate Press, Inc., designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities certified for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Physician assistants may receive a maximum of 0.5 hours of Category I credit for completing this program.

To obtain credit for this activity, study the material and complete the CME Posttest and Evaluation.

Release, Review, and Expiration Dates

This Neurology Report was published in February 2012 and is eligible for AMA PRA Category 1 Credit™ through February 28, 2015. The latest review of this material was January 2012.

Statement of Need and Purpose

Chronic pain is the leading reason patients see their primary care physician, and it accounts for a great number of emergency room visits and days missed from work. Chronic pain reduces a patient’s physical, mental, and social functioning capacity, making it one of the most disabling and costly health issues in America. Unfortunately, symptoms of chronic pain are frequently either undertreated or overtreated. Successful management of pain symptoms, whether acute or chronic, is essential for patients to experience full functional abilities and a positive quality of life. Opioids are frequently used to treat both chronic and acute pain, but many clinicians have concerns about the potential for abuse and addiction associated with these agents. This activity was designed to meet the needs of participants in CME activities provided by the CME Institute of Physicians Postgraduate Press, Inc., who have requested information on chronic pain.

Disclosure of Off-Label Usage

Dr Parker has determined that, to the best of his knowledge, no investigational information about pharmaceutical agents that is outside US Food and Drug Administration–approved labeling has been presented in this activity.

Review Process

The entire faculty of the series discussed the content at a peer-reviewed planning session, the Chair reviewed the activity for accuracy and fair balance, and a member of the External Advisory CME Board who is without conflict of interest reviewed the activity to determine whether the material is evidence-based and objective.

Acknowledgment

This Neurology Report was derived from an interview with Autry J. Parker, MD, MPH, on August 8, 2011. This activity is one in a series of independent projects undertaken by the CME Institute of Physicians Postgraduate Press, Inc., as a service to its members and the broader academic and clinical community. The opinions expressed herein are those of the faculty and do not necessarily reflect the opinions of the CME provider and publisher.