The Initiation of Chronic Opioids: A Survey of Chronic Pain Patients

This study reports the results of a researcher-administered survey with 115 patients receiving chronic opioid therapy (>90 days) to obtain information regarding how chronic opioid therapy was started. Chronic opioids were started after surgery (27.0%, 95% confidence interval [CI], 18.5–35.5) or for the treatment of acute injury-related pain (27.0%, 95% CI, 18.5–35.5). Many who initiated opioid therapy after surgery reported postoperative complications (61.3%, 95% CI, 50.8–71.8) and many with injury-related pain reported follow-up corrective surgery (58.1%, 95% CI, 47.5–68.7), which led to the continuation of opioids. A large percentage of patients had concurrent depression (43.5%, 95% CI, 34.0–53.0) and anxiety (23.5%, 95% CI, 15.3–31.7). Many participants had a medical history of aberrant drug-related behavior (32.5%, 95% CI, 23.5–41.5) and self-reported history of addiction (21.7%, 95% CI, 13.7–29.7). Almost one-quarter reported taking opioids for a different indication than that for which opioids were started (95% CI, 26.6–45.0). Patients receiving long-term opioid therapy often transitioned to chronic use after starting opioids for the short-term treatment of postoperative or injury-related pain. It is not evident if a clear decision to continue opioids on a chronic basis was made. This survey provides insight as to how chronic opioid therapy is started, and may suggest opportunities for improved patient selection for opioid therapy.

Overdose Risk with Opioids for Chronic Noncancer Pain

ABSTRACT

Timely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Clinical scenarios, symptoms, interventions, and treatment-related adverse events addressed in this issue are overdose risk with opioids in chronic pain; pain in the primary care setting; methadone products and risk of QT prolongation; zolendronic acid and circulating cancer cells; statins and deep venous thrombosis; and treatment for cancer-associated anorexia-cachexia syndrome.     

Adherence to Medication Guideline Criteria in Cancer Pain Management

The medication-assessment tool for cancer pain management (MAT-CP) is a novel tool for measuring the quality of drug use in chronic pain management in relation to guideline standards. MAT-CP has recently been revised and validated for use in the U.K. clinical setting. This article presents a measure of the adherence of current practice to specific cancer pain guideline criteria in two palliative care settings. Adult patients with malignant disease experiencing pain and/or receiving analgesics were identified by clinical pharmacists at two hospitals and five hospices in Scotland, United Kingdom. The MAT-CP was applied to data extracted from case notes. Results were quantified in terms of applicability and adherence to guideline criteria and the presence of insufficient data. MAT-CP was applied to 192 cancer patients experiencing pain; 103 (54%) were males and the mean (standard deviation) age was 68.5 (13.0) years. Overall guideline adherence was 75% (confidence interval [CI]: 74%, 77%; n = 3460 applicable criteria). Low adherence (<50%) was seen for nine criteria, whereas 21 criteria were considered high-adherence criteria (>75%). Overall adherences for 56 (29%) hospitalized patients and 136 (71%) hospice patients were 65% (CI: 62%, 68%) and 79% (CI: 78%, 81%), respectively. Although good overall guideline adherence was found, there were gaps in both the hospice and hospital palliative care settings in the implementation of certain treatment recommendations, particularly in relation to pain assessment. The application of the tool has highlighted issues for feedback to health care providers and for further study.     

The Role of Opioids in Cancer Pain Management

Abstract:   Opioids remain an important cornerstone in the treatment of cancer pain. Effective analgesia is obtained in the majority of cancer pain patients with the application of fairly straightforward algorithms using opioids as the main therapy. Many rational treatment algorithms exist. In this tutorial we will describe the role of opioids in the treatment of cancer pain, including a brief overview of cancer pain syndromes, essential aspects of opioid therapy, opioid pharmacology, opioid rotation, properties of the individual opioids, and management of common side effects of opioids.     

The White Paper on Opioids and Pain

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.     

An Educational Strategy for Treating Chronic,Noncancer Pain With Opioids: A Pilot Test

Chronic pain is common and can be devastating to the patient and challenging to the health care provider. Despite the importance of the topic, pain management curricula are incomplete in health professionals' training. We developed a longitudinal curriculum to teach therapy for chronic noncancer pain over four units and pilot-tested the teaching of one unit (opioids) to internal medicine residents. The educational strategies we used included didactic sessions, write-up of a management plan following a model, case discussions, and role-play group activities. We pilot-tested one unit (opioid therapy) in March 2008. We performed learner evaluations, using a pretest and posttest, a write-up plan following a model, and a learner knowledge questionnaire. Results showed significant improvement in knowledge. Residents found the sessions and educational strategy to be excellent and reported higher confidence levels in managing patients with chronic noncancer pain.     

Treatment of Chronic Pain by Long‐Acting Opioids and the Effects on Sleep

Chronic pain affects a substantial part of the population, and conveys a huge economic cost to society. Owing to its prevalence and adverse impact, it is of particular interest to clinicians, patients, and the pharmaceutical industry. Conversely, the effects of pain on sleep, sleep on pain, and opioid analgesics on sleep represent a large gap in our understanding, even though pain and sleep are closely linked, inter‐related conditions. Chronic pain is often treated by opioid analgesics, which are often thought to promote restful sleep. Indeed it may be assumed that by relieving pain, sleep quality will improve concomitantly. In fact, the reality is much more complicated. The effects of opioids vary according to their formulation and duration of action, and have diverse effects on sleep processes. Despite the prevalence of this problem, there is a surprising paucity of data on the effects of opioids on sleep. This review attempts to summarize the links between pain and sleep, and to look at the studies with opioid analgesics, particularly those with extended‐release formulations, that have investigated the effects of opioid analgesics on sleep.