Opioids in Chronic Pain Management:  Benefits and Risks

Side effects:  constipation, sleep disruption, altered mental status, itching, nausea, respiratory depression

Addiction vs. Dependence

Assessing whether medication improves quality of life and participation in life or diminishes them

Benefits of Opioids for Pain

Opioids “take the edge off pain” or “make it easier to manage it”

Opioids do not eliminate pain, in therapeutic doses

Goals of Opioid Use

In Cancer Pain:  Improved Quality of Life

Relief of suffering, even if there is sedation, etc.

In Nonmalignant Pain: Improved Function

Timing

Reminder on the role and proper use of long-acting pain medication vs. “breakthrough”, short-acting medication

Side Effects of Opioids

Nausea and Vomiting

Constipation

Sedation- sleepiness

Respiratory depression

Urinary retention (difficulty peeing)

Dysphoria – depression

Gonadal atrophy

Myoclonus, muscular rigidity

Increase in Pain Sensitivity**

Opioid-induced Hyperalgesia

Animal studies show that repeated opioid administration. . . can lead to a progressive and lasting reduction of baseline nociceptive thresholds, resulting in an increase in pain sensitivity.

The decreased baseline nociceptive thresholds lasted as long as 5 days after the cessation of four fentanyl bolus injections

Six chronic low back pain patients were assessed for both opioid tolerance and opioid-induced hyperalgesia using quantitative sensory testing (cold and heat) before and after the institution of oral morphine therapy. 

Preliminary results showed hyperalgesia and tolerance with cold but no hyperalgesia with heat or analgesic tolerance to heat pain.

Patients treated intraoperatively with remifentanil reported more postoperative pain than the matched nonopioid controls

A number of case reports document decreases in pain with stopping opioids

Wilson G.R., Reisfield G.M.:  Morphine hyperalgesia: a case report.  Am J Hosp Palliat Care 20. (6): 459-461.2003
 Mercadante S., Ferrera P., Villari P., et al:  Hyperalgesia: an emerging iatrogenic syndrome.  J Pain Symptom Manage 26. (2): 769-775.2003; 

 Heger S., Maier C., Otter K., et al:  Morphine induced allodynia in a child with brain tumour.  BMJ 319. (7210): 627-629.1999; 

 Sjogren P., Jensen N.H., Jensen T.S.:  Disappearance of morphine-induced hyperalgesia after discontinuing or substituting morphine with opioid agonists.  Pain 59. 313-316.1994;

Mechanism may be NMDA receptor-mediated central sensitization

Some Definitions

Tolerance      is a state resulting from regular use of opioid(s) in which an increased dose of the substance is needed to produce the desired effect.

Physical dependence          is a physiologic state of adaptation to a specific opioid(s) characterized by the emergence of a withdrawal syndrome during abstinence, which may be relieved in total or in part by re-administration of the substance.

Withdrawal syndrome          is a specific constellation of signs and symptoms due to the abrupt cessation of, or reduction in, a regularly administered dose of opioid(s).

Addiction       is a disease process involving use of opioid(s) wherein there is a loss of control, compulsive use, and continued use despite adverse social, physical, psychological, occupational, or economic consequences.

Pseudoaddiction – Medication-seeking behaviors that arise as a result of pain being poorly controlled

Substance abuse     is the use of any substance(s) for non-therapeutic purposes; or use of medication for purposes other than those for which it is prescribed.

          Patients                    vs.                                              Addicts

Control of medication                                                  Med use not controlled

Medications increase quality of life                            Medications decrease quality of life

Medications are decreased if side effects occur      Medications continued in the face of side effects

Concerned about medical problem                            Lack of concern about medical problems           

Follow the contract                                                       Ignore the contract

Medications left over                                                   Never have medication left; often have              

                                                                                         stories about drug losses and shortages

Addiction in Patients with Chronic Pain

(1)  Intense desire for the drug and overwhelming concern about its continued availability (psychological dependence)

(2)  Evidence of compulsive drug use

 unsanctioned dose escalation

continued dosing despite significant side effects

Use of drug to treat symptoms not targeted by therapy

Unapproved use during period of no symptoms

Or

(3) Evidence of one or more of a group of associated behaviors

 manipulation of the treating physician or medical system for the purposes of obtaining additional drug (altering prescriptions, for example)

Acquisition of drugs from other medical sources or from a nonmedical source

Drug hoarding or sales

Unapproved use of other drugs (particularly alcohol or other sedatives/hypnotics) during opioid therapy

Questions to Ask:

Is the person’s day centered around taking medication?

Does the person take pain medication only on occasion, perhaps three or four pills per week?

Have there been any other chemical (alcohol or drug) abuse problems in the person’s life?

Does the person in pain spend most of the day resting, avoiding activity, or feeling depressed?

Is the pain person able to function (work, household chores, and play) with pain medication in a way that is clearly better than without?

Signs Someone Is Being Harmed More Than Helped by Pain Medication

Sleeping too much or having days and nights confused

Decrease in appetite

Inability to concentrate or short attention span

Mood swings (especially irritability)

Lack of involvement with others

Difficulty functioning due to drug effects

Use of drugs to regress rather than to facilitate involvement in life

Lack of attention to appearance and hygiene

Addiction Issues with Non-Opioids

Many of the same questions apply when looking at use of

Muscle Relaxants

Cannabis

Other adjunctive medications –

Anticonvulsants

Etc.

Adjunctive Medications

Topical – lidocaine, capsaicin, antiinflammatories, other

Antidepressants

Anticonvulsants

Antiarrhythmic drugs

Ultram

Antidepressants for Pain

Work by affecting neurotransmitters

Do not only work for treating pain by improving depression.

Work as well in non-depressed people as in people with depression

Effectiveness for pain does not correlate with effectiveness for depression

Do not work for all types of pain.

Stopping or Tapering Opioids

Withdrawal Symptoms

Anxiety/Restlessness

Sweating

Insomnia

Diarrhea

Nausea, vomiting

Yawning, rhinorrhea (runny nose)

Transient increase in pain

Treatment of Withdrawal

Each of the symptoms of withdrawal can be treated, and herbal support is also available for opioid withdrawal

Passionflower

Clonidine

Lomotil

Hydroxyzine

Trazodone

Etc.