Safe use of opioids in chronic noncancer pain

Many physicians avoid prescribing opioid analgesics for chronic pain because of misconceptions or fears about efficacy, adverse effects, abuse, and addiction potential. We discuss these issues and offer suggestions for the rational use of opioid analgesics in patients with chronic noncancer pain.     

The White Paper on opioids and pain: a pan-European challenge: the European White Paper on the use of opioids in chronic pain management

This document was developed by a group of over two dozen pain clinicians and investigators from Austria, Belgium, Denmark, France, Germany Ireland, Israel, Italy, The Netherlands, Norway, Poland, Portugal. Spain, Sweden, Switzerland and the United Kingdom and funded by an educational grant form Mundipharma International, Limited. The stated aim of the White Paper is to identify inequalities in government policies towards opioids that contribute to inadequate treatment of pain. It calls for their replacement with policies that will support doctors and patients in their efforts to relieve pain.     

Evolution of a rational use of opioids in chronic pain

Since the isolation of morphine from opium by Serturner in 1806, morphine, which Osler referred to! as 'God's own medicine', has remained the analgesic of choice for the treatment of severe pain despite its known addictive potential and the attempts to replace it with synthetic or semi-synthetic medications. Its early use was based on clinical experience alone until the identification of the opioid receptors and endogenous opioids 25 years ago. Advances in pharmacology and pharmacokinetics and the development of precision equipment to quantify the parent drugs and their metabolites in plasma have provided a better understanding of the mechanisms of action as well as adverse effects. Clinicians can now select the drug and route of administration to suit the patient's needs. The objective of care now is for clinical observation to be reinforced by randomized controlled trials and evidence-based medicine, but controlled clinical trials are lacking for the use of opioids in chronic pain.     

Pain management autobiographies and reluctance to use opioids for cancer pain management

Although pain management education results in improved pain control for some patients, it does not work for all patients because some patients remain reluctant or unwilling to use prescribed analgesics to their optimal effect. In a randomized clinical trial that tested the effectiveness of the PRO-SELF Pain Control Program, 11 patients declined to increase their analgesic use despite moderate to severe pain. These patients were selected for a qualitative analysis of their audiotaped discussions about pain management with their intervention nurses. This analysis revealed that these patients often spontaneously provided detailed explanations about why they were reluctant or unwilling to take analgesics in general or opioids in particular. We termed these explanatory accounts pain management autobiographies because of their narrative character and multilayered, richly detailed quality. Pain management autobiographies included stories about (1) previous experience with chronic pain management, including stigmatizing interactions with clinicians and family members; (2) bad experiences with cancer pain management, including severe constipation; and 3) strongly held conventions about medication use, including the belief that all medications are "toxins" that should be avoided. The study findings suggest that a small subset of patients with cancer pain may need interventions such as individual or family counseling or alternative pain management strategies to augment education about opioids.     

Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review

Opioids have been endorsed as appropriate treatment for refractory chronic non-cancer pain when used according to published guidelines. They are widely used for this indication. However, there appear to be gaps in our understanding of the efficacy and safety of individual long-acting opioids compared to each other or as a class compared to short-acting opioids. This systematic review summarizes and assesses the evidence for the comparative efficacy and safety of long-acting opioids in the management of chronic non-cancer pain. Randomized trials (for comparative efficacy and adverse events) and observational studies (for adverse events only) that included non-parenteral long-acting opioids were sought using electronic databases, handsearching reference lists, and soliciting pharmaceutical company submissions. Searches were performed through October 2002. The validity of each included study was assessed using a data abstraction form and predefined criteria. An overall grade was allocated for the body of evidence for each key question. A total of 16 randomized trials (comparative efficacy and adverse events), enrolling 1427 patients, and 8 observational studies (adverse events) of 1190 patients were included in this review. No randomized trial was rated good quality; observational studies were generally of poorer quality than the trials. There was insufficient evidence to prove that different long-acting opioids are associated with different efficacy or safety profiles. There was also insufficient evidence to determine whether long-acting opioids as a class are more effective or safer than short-acting opioids. A subgroup of three studies on long-acting versus short-acting oxycodone was more homogeneous and provided fair evidence that these formulations are equally effective for pain control.     

A population-based study on chronic pain and the use of opioids in Portugal

Although increasing doubts exist regarding the long-term effectiveness and safety of opioids in patients with chronic pain (CP), most guidelines still recognize opioids as an option in effective management of CP. We aimed to describe the prevalence and factors associated with opioid use in subjects with CP in Portugal and to evaluate satisfaction and self-assessed treatment effectiveness. A nationwide study was conducted in a representative sample of the adult Portuguese population. The 5094 participants were selected using random digit dialing and estimates were adequately weighted for the population. The prevalence of opioid use by subjects with CP was 4.37% (95% confidence interval [CI] 3.4–5.5); and in subjects experiencing CP with and without cancer, it was 10.13% and 4.24%, respectively. Use of strong opioids was reported by only 0.17% of CP subjects. Sex, pain severity and symptoms of depression and anxiety were significantly associated with opioid use; however, in multivariate modeling, only pain-related disability remained significant. No significant differences among users and nonusers of opioids were observed regarding treatment satisfaction and self-assessed effectiveness. Although extremely high rates of use of opioids exist in a few countries, it should not be seen as a ubiquitous problem. Indeed, we showed that in Portugal, as in many other regions in the world, opioids are used much less frequently than in those few countries. Moreover, we did not find significant differences among users and nonusers of opioids regarding satisfaction and self-assessed effectiveness, eventually showing the results to be in line with reports that show doubt about opioids’ effectiveness. Further research and particular attention to and continuous monitoring of the trends of use and abuse of opioids worldwide are recommended.     

Managing chronic nonmalignant pain: Overcoming obstacles to the use of opioids

Physicians involved in cancer pain management treat thousands of patients with opioids, whose effective analgesia improves overall functioning. Side effects generally are tolerable, and treatment can be maintained with stable doses for long periods. Problems with addiction are infrequent. Many physicians, however, assume that opioids should be used only for chronic malignant pain. Research and clinical experience have demonstrated that opioids can safely and effectively relieve most chronic moderate to severe nonmalignant pain. Fears of addiction, disciplinary action, and adverse effects result in ineffective pain management. With current information on the use of opioids in chronic nonmalignant pain, primary care physicians can overcome these obstacles. Guidelines must clearly define the role of the primary care physician in the proper management of pain and the integration of opioid therapy. Used appropriately, opioids may represent the only source of relief for many patients.     

Outcome of intrathecal opioids in chronic non-cancer pain

Eighty-eight patients (58 women and 30 men; mean age 53.4 years) with chronic non-cancer pain present on average for 9.8 years were evaluated following treatment with intrathecal opioids for an average duration of 36.2 months. Outcome measures were global pain relief, physical activity levels, medication consumption, work status, intrathecal opioid side-effects, proportion of patients who ceased therapy and patient satisfaction. The most common diagnosis in this group was lumbar spinal or radicular pain after failed spinal surgery (n= 55, 63%). At the time of follow-up, mean pain relief was 60% with 74% of patients (36 of 49) reporting increased activity levels. Oral medication intake was significantly reduced (Medication Quantification Scale Score prior to implantation 31.0+/-2.6 and at follow-up 12.7+/-1.4; n= 48; p< 0.0001). These gains were not accompanied by a change in work status (43 of 50 working age patients not working at follow-up). There were frequent reports of opioid side-effects, including sexual dysfunction and menstrual disturbance. Technical complications occurred with the drug administration device, most often catheter related, requiring at least one further surgical procedure in 32 patients (40%). Patient satisfaction with intrathecal opioids was high, with 45 of 51 (88%) reporting satisfaction. Mean intrathecal morphine dose increased from 9.95+/-1.49 mg/day (mean+/-SEM) at 6 months to 15.26+/-2.52 mg/day 36 months after initiation of therapy. Drug administration systems were permanently removed in five patients (6%). Intrathecal opioid therapy appears to have a place in the management of chronic non-cancer pain. Therapy does not seem to be significantly inhibited by the development of tolerance.     

Spinal opioids in the management of obstetric pain

Spinal opioids have become increasingly popular agents for providing analgesia during labor, augmenting anesthesia during cesarean section, and providing pain relief after operative delivery. The development of spinal opioids in the management of obstetric pain is reviewed.     

The role of spinal opioids in the management of cancer pain

Spinal opioids have dramatically influenced the way intractable pain of malignant origin is managed. To provide optimal pain relief, spinal opioids must be used in the context of a comprehensive cancer pain management treatment plan. The choice of epidural versus subarachnoid route of administration, as well as the specific opioids administered, require assessment of the individual needs of the patient. Factors likely to influence patient selection, including physiologic and behavioral abnormalities that may interfere with the patients' ability to assess pain relief, must be considered. During therapy, side effects must be anticipated and treated aggressively to assure patient comfort and safety. Although the chronic administration of opioids and other drugs into the epidural or subarachnoid space is in its infancy, advances in the pharmacology of spinal drugs and the development of new delivery system technology will probably expand the options available for the relief of cancer pain.     

Best practice of pain management with opioids

Opioids are main drugs in pain management for terminal cancer patients. In these days, we have to choice suitable opioids for the terminal cancer patients with severe pain by opioids rotation. Morphine is a basic drug in opioids. To know about character of morphine make us easy for using other opioids. In this article, character and some points in using opioids were described in detail. For example, timing for administrating opioids, titration, rescue dose, and side effects were included in this article. We don't have to remember the aim of pain management. Pain control is not a purpose, but a way for keeping QOL of the terminal cancer patients.     

Opioid use in the management of chronic pain.

Opioids are a necessary and effective component of the management of chronic non-cancer-related pain in some patients. Careful structuring, monitoring, and documentation of care are important, but the therapeutic use of opioids is uncomplicated in the majority of patients using opioids and is gratifying for both the patient and the treating physician when it results in significant reduction in pain, improvement in level of function, and a higher quality of life. Opioid therapy is most often successful when combined with other pharmacologic and nonpharmacologic interventions as indicated by the type of pain and the context in which it occurs.