Chronic pain and opiate management
Introduction
The words chronic pain and opiates are too often spoken in the same context; almost to infer a symbiotic relationship between the two, as if opiates are the answer to chronic pain and chronic pain commands the use of opiates.
How did we get here in this epidemic of “prescription opioid abuse, overdoses, and death?”1 How did we as a nation that makes up 5% of the world population come to consume 80% of the world’s opiates?2 And most importantly, has this consumption positively impacted our overall function and pain?
A review of our nation’s history on pain management will help providers to understand better and to respond to the mixed messages that are being conveyed as “proper management of opiates in chronic pain.” All of our actions and responses have shaped us into the providers we are today. And though there exists a constant flux of changes to the opioid-prescribing guidelines presented to us, a common thread can be seen. That more is no longer always the solution, and that in fact, the previously taught principle of “titrate to effect: the correct dose of an opioid was whatever dose provided pain relief as measured by a pain intensity scale”1 was flawed when expanding tenets previously originating from the treatment of pain in cancer patients to this new medically diverse and complex population of chronic non-cancer-related pain patients.
When the Joint Commission introduced a mandate that the pain be recognized and treated, the American Pain Society began in 1996 the promotion and push for Pain as the “fifth vital sign.” Dr. James Campbell, in his November 1996 Presidential Address for the American Pain Society noted, “vital signs are taken seriously. If pain were assessed with the same zeal as other vital signs are, it would have a much better chance of being treated properly. We need to train doctors and nurses to treat pain as a vital sign. Quality care means that pain is measured and treated.”3 The VA went on to establish a toolkit designed to promote “Pain as the 5th Vital Sign” and to offer guidelines for the completion of comprehensive pain assessments. Many other pain organizations followed suit and universally, healthcare providers were pushed to inquire about and directly address and treat patient’s pain.
Mistakenly, information was also conveyed to practitioners that by prescribing opiate medications, the risk for adverse outcomes such as addiction and misuse were low, thus liberating prescribers to feel a false sense of safety. Unfortunately, studies up until that point had focused primarily on studying the use of opiates in cancer pain patients and not in chronic non-cancer (or non-malignant) related pain. These non-cancer-related pain patients exposed to chronic opiate therapies proved to be a completely unique subset of patients with pain originating from multifactorial contributions. The complexity of their disease combined with significant socioeconomic stressors and psychiatric/psychological overlay led to much higher rates of addiction and misuse than previously seen in the cancer pain population.
In 1982, the World Health Organization (WHO) brought together a group of cancer pain consultants to develop a practice regimen for global education and dissemination. This set of guidelines recommended that a physician prescribe analgesics on a regular schedule and titrate dosage to the patient’s pain at each of the three steps.4 These guidelines completed in 1996 now remain the conceptual framework for the management of pain. The ladder system directs pharmacological treatment of pain based on subjective pain reports of patients using the numeric rating scale 0–10. Based upon the numeric rating, patients are categorized to have mild (1–3), moderate (4–6), or severe (7–10) pain.
In step 1 (mild pain, 1–3) of the ladder, non-opiate pain medications such as aspirin, acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), and adjuvant analgesics are recommended. In step 2 (moderate pain, 4–6) of the ladder, certain opiate pain medications such as hydrocodone, oxycodone, codeine, and tramadol were recommended in addition to all drugs in step 1. In step 3 (severe pain, 7–10) of the ladder, more potent opiates such as morphine, hydromorphone, methadone, and fentanyl were added in addition to all drugs in steps 1 and 2. This ladder was developed with the intention of serving as a guide for prescribers to be used in conjunction with clinical judgment and experience.5
With the publication of studies reporting the safety and efficacy of opioids prescribed to a small number of patients with chronic non-malignant pain combined with the publication of a seminal article entitled “The Tragedy of Needless Pain”6 and the push for “Pain as the 5th vital sign,” the use of opioids to treat chronic non-cancer-related pain (non-malignant pain) became more widely practiced and incorporated into clinical guidelines.7
Section snippets
The cost of opioid prescribing
The use of opioids for chronic pain began to increase, showing a substantial year-to-year rise that continues today. The increase use of opioids for legitimate medical purposes has been accompanied by a substantial increase in the prevalence of non-medical use of prescription opioids. In late 1995, OxyContin was approved by the FDA and marketed heavily for safe and effective use in chronic non-cancer-related pain management. Unfortunately, for Americans and the medical community, this rapid
Reducing risk for opioid prescribing
Addiction to opiates is a result of a complex interaction between the person at risk and properties of the drug. Risk factors for addiction should be screened by every clinician planning to initiate or continue opiate therapies for any patient. Complete and thorough risk assessment includes evaluating for any history of substance dependence (personal or family history), history of personal or family psychiatric history, and a personal history of pre-adolescent sexual abuse.13 Percentage of
Neurobiology of opioid analgesics
Opioids derived from the poppy plant opium have been used for pain relief as far back as 4000 BC. Morphine, the pure active ingredient was isolated in 1803 by Friedrich Serturner of Germany. In 1874, as scientists working with the molecule added two acetyl groups, unexpectedly heroin was synthesized (diacetylmorphine) and briefly promoted as more effective and less addictive than morphine.7 Heroin was legally marketed in the pill form in the early 20th century before leading to aberrant use by
Non-opioid analgesics
While non-steroidal anti-inflammatory drugs (NSAIDs) are both analgesic and anti-inflammatory, acetaminophen is only analgesic. Both are limited by a ceiling effect at which point increasing the dose fails to provide further efficacy but may increase adverse effects. Acetaminophen is metabolized in the liver and its reactive metabolite can cause liver damage and thus while prior FDA recommendations advised maximum dosing of 4000 mg/day, recent suggestions advise no more than 3000–3250 mg/day for
Codeine
Codeine is a weak mu agonist available in oral formulation. Codeine is metabolized to morphine followed by conjugation to form hydrocodone. Codeine has peak effect between 30 and 60 min and effects can last 3–6 h in duration. Due to genetic polymorphisms, 10% of the population will be unable to metabolize codeine due to the absence of the CYP2D6 enzyme.
Morphine
Morphine is available in multiple formulations and is available in oral, parenteral (subcutaneous, intramuscular, and intravenous), rectal, or
Guidelines and future directions
The American Pain Society (APS), American Academy of Pain Management (AAPM) in 2009, Veterans Affairs/Department of Defense (VA/DOD) in 2010, and various other organizations have developed pain management guidelines to help clinicians seek a balanced approach to opioid use for chronic non-cancer-related pain. These guidelines recommend a “universal precautions” approach involving careful patient selection and risk assessment for those patients with moderate-to-severe pain.26 Though in July
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