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Kwon AH, Colloca L, Mackey SC. Blinded Pain Cocktails: A Reliable and Safe Opioid Weaning Method. Anesthesiol Clin 2023; 41:371-381. [PMID: 37245948 DOI: 10.1016/j.anclin.2023.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Weaning opioids in patients with noncancerous chronic pain often poses a challenge when psychosocial factors complicate the patient's chronic pain syndrome and opioid use. A blinded pain cocktail protocol used to wean opioid therapy has been described since the 1970s. At the Stanford Comprehensive Interdisciplinary Pain Program, a blinded pain cocktail remains a reliably effective medication-behavioral intervention. This review (1) outlines psychosocial factors that may complicate opioid weaning, (2) describes clinical goals and how to use blinded pain cocktails in opioid tapering, and (3) summarizes the mechanism of dose-extending placebos and ethical justification of its use in clinical practice.
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Affiliation(s)
- Albert Hyukjae Kwon
- Stanford University School of Medicine, 430 Broadway Street, Pavilion C, 3rd Floor, Redwood City, CA 94063, USA.
| | - Luana Colloca
- Pain and Translational Symptom Science, Placebo Beyond Opinions Center, School of Nursing, University of Maryland, Baltimore, 655 West Lombard Street, Room 729A, Baltimore, MD 21201, USA
| | - Sean C Mackey
- Stanford University School of Medicine, 1070 Arastradero Road, Suite 200, Palo Alto, CA 94304, USA
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2
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Bruneau A, Poirier C, Bérubé M, Boulanger A, Gélinas C, Guénette L, Lacasse A, Lussier D, Tousignant-Laflamme Y, Pagé MG, Martel MO. French-Canadian Translation and Cultural Adaptation of the Clinical Opiate Withdrawal Scale: The COWS-FC. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2022; 67:701-711. [PMID: 35290134 PMCID: PMC9449138 DOI: 10.1177/07067437221087066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The main objective of the present study was to develop a French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) for the assessment of opioid withdrawal symptoms in clinical and research settings. METHODS The French-Canadian translation and cultural adaptation of the COWS was performed following guidelines for the translation and cross-cultural adaptation of self-report measures. The steps consisted of (1) initial translation from English to French, (2) synthesis of the translation, (3) back-translation from French to English, (4) expert committee meeting, (5) test of the prefinal version among healthcare professionals and (6) review of final version by the expert committee. The expert committee considered four major areas where the French-Canadian version should achieve equivalence with the original English-version of the COWS. These areas were (1) semantic equivalence; (2) idiomatic equivalence; (3) experiential equivalence and (4) conceptual equivalence. RESULTS Rigorous steps based on the guidelines for the translation and cultural adaptation of assessment tools were followed, which led to a semantically equivalent version of the COWS. After a pretest among healthcare professionals, members from the expert committee agreed upon slight modifications to the French-Canadian version of the COWS to yield a final COWS-FC version. CONCLUSIONS A French-Canadian translation and adaptation of the COWS (i.e., the COWS-FC) was developed. The COWS-FC could be used for the assessment of opioid withdrawal symptoms in clinical and research settings.
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Affiliation(s)
- Alice Bruneau
- Faculty of Medicine, 5620McGill University, Montreal, Quebec, Canada
| | - Clarice Poirier
- Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Mélanie Bérubé
- Faculty of Nursing, Université Laval, Québec City, Quebec, Canada.,177460Centre de recherche du Centre hospitalier universitaire de Québec, Population Health and Optimal Health Practices Research Unit, Québec City, Quebec, Canada
| | - Aline Boulanger
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Pain Clinic, Centre hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Céline Gélinas
- Ingram School of Nursing, 5620McGill University, Montreal, Quebec, Canada
| | - Line Guénette
- 177460Centre de recherche du Centre hospitalier universitaire de Québec, Population Health and Optimal Health Practices Research Unit, Québec City, Quebec, Canada.,Faculty of Pharmacy, 4440Laval University, Quebec City, Quebec, Canada
| | - Anaïs Lacasse
- Department of Health Sciences, 7001Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, Quebec, Canada
| | - David Lussier
- Centre de recherche, l'Institut universitaire de gériatrie de Montréal du CIUSSS du Centre-Sud-de-l'Ile-de Montréal, Montreal, Quebec, Canada.,Département de médecine, Faculté de médecine, Université de Montréal, Montreal, Quebec, Canada
| | - Yannick Tousignant-Laflamme
- School of Rehabilitation, Faculty of Medicine and Health Sciences, 7321Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - M Gabrielle Pagé
- Department of Anesthesiology and Pain Medicine, Faculty of Medicine, Université de Montréal, Montreal, Quebec, Canada.,Centre de recherche, Centre hospitalier de l'5622Université de Montréal (CRCHUM), Montreal, Quebec, Canada
| | - Marc O Martel
- Faculty of Dentistry & Department of Anesthesiology, 5620McGill University, Montreal, Quebec, Canada
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3
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Avery N, McNeilage AG, Stanaway F, Ashton-James CE, Blyth FM, Martin R, Gholamrezaei A, Glare P. Efficacy of interventions to reduce long term opioid treatment for chronic non-cancer pain: systematic review and meta-analysis. BMJ 2022; 377:e066375. [PMID: 35379650 PMCID: PMC8977989 DOI: 10.1136/bmj-2021-066375] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To review interventions to reduce long term opioid treatment in people with chronic non-cancer pain, considering efficacy on dose reduction and discontinuation, pain, function, quality of life, withdrawal symptoms, substance use, and adverse events. DESIGN Systematic review and meta-analysis of randomised controlled trials and non-randomised studies of interventions. DATA SOURCES Medline, Embase, PsycINFO, CINAHL, and the Cochrane Library searched from inception to July 2021. Reference lists and previous reviews were also searched and experts were contacted. ELIGIBILITY CRITERIA FOR STUDY SELECTION Original research in English. Case reports and cross sectional studies were excluded. DATA EXTRACTION AND SYNTHESIS Two authors independently selected studies, extracted data, and used the Cochrane risk-of-bias tools for randomised and non-randomised studies (RoB 2 and ROBINS-I). Authors grouped interventions into five categories (pain self-management, complementary and alternative medicine, pharmacological and biomedical devices and interventions, opioid replacement treatment, and deprescription methods), estimated pooled effects using random effects meta-analytical models, and appraised the certainty of evidence using GRADE (grading of recommendations, assessment, development, and evaluation). RESULTS Of 166 studies meeting inclusion criteria, 130 (78%) were considered at critical risk of bias and were excluded from the evidence synthesis. Of the 36 included studies, few had comparable treatment arms and sample sizes were generally small. Consequently, the certainty of the evidence was low or very low for more than 90% (41/44) of GRADE outcomes, including for all non-opioid patient outcomes. Despite these limitations, evidence of moderate certainty indicated that interventions to support prescribers' adherence to guidelines increased the likelihood of patients discontinuing opioid treatment (adjusted odds ratio 1.5, 95% confidence interval 1.0 to 2.1), and that these prescriber interventions as well as pain self-management programmes reduced opioid dose more than controls (intervention v control, mean difference -6.8 mg (standard error 1.6) daily oral morphine equivalent, P<0.001; pain programme v control, -14.31 mg daily oral morphine equivalent, 95% confidence interval -21.57 to -7.05). CONCLUSIONS Evidence on the reduction of long term opioid treatment for chronic pain continues to be constrained by poor study methodology. Of particular concern is the lack of evidence relating to possible harms. Agreed standards for designing and reporting studies on the reduction of opioid treatment are urgently needed. REVIEW REGISTRATION PROSPERO CRD42020140943.
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Affiliation(s)
- Nicholas Avery
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Amy G McNeilage
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona Stanaway
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Claire E Ashton-James
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
| | - Fiona M Blyth
- Pain Management Research Institute, Kolling Institute, University of Sydney, Sydney, NSW, Australia
- School of Public Health, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Rebecca Martin
- Michael J Cousins Pain Management and Research Centre, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Ali Gholamrezaei
- Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Fishbain DA. Opioid Tapering/Detoxification Protocols, A Compendium: Narrative Review. PAIN MEDICINE 2021; 22:1676-1697. [PMID: 33860319 DOI: 10.1093/pm/pnab019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES The opioid epidemic has put pressure on clinicians to taper their chronic pain patients (CPPs) from opioids. This has resulted in rapid or forced tapers and opioid discontinuation. Partially responsible is lack of information on how to taper (tapering protocols).The objectives of this narrative review were then the following: compile all the published opioid tapering/detoxification protocols from the pain/drug rehabilitation/psychiatric literature whether for inpatient or outpatient use; organize these into general types; compare the types for advantages/disadvantages for use by a clinician in an outpatient setting; and answer some commonly asked questions relating to opioid tapering. METHODS Relevant references were identified by a search strategy utilizing the terms tapering, tapering protocols, detoxification, detoxification protocols, withdrawal, dependence, addiction, and drug rehabilitation. These were explored with the term opioids. Identified abstract were reviewed for any study relating to the objectives of this review. Those studies were then included in this review. As this is a narrative review, no quality ratings of these references were performed. RESULTS Of 1,922 abstracts identified by this search strategy, 301 were reviewed in detail for potential inclusion. Of these, 104 were utilized in this review. Nine types of opioid tapering protocols were identified and compared in tabular form. Twenty-two questions in reference to opioid tapering were addressed. CONCLUSIONS Based on this review, the protocol utilizing the opioid of current use is the simplest to use as it requires no rotation to another opioid and thereby avoids rotation errors. It also has behavior advantages.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Neurological Surgery, Miller School of Medicine at the University of Miami, Miami, Florida, USA.,Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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Dasgupta N, Wang Y, Bae J, Kinlaw AC, Chidgey BA, Cooper T, Delcher C. Inches, Centimeters, and Yards: Overlooked Definition Choices Inhibit Interpretation of Morphine Equivalence. Clin J Pain 2021; 37:565-574. [PMID: 34116543 PMCID: PMC8270512 DOI: 10.1097/ajp.0000000000000948] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 02/26/2021] [Accepted: 04/23/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Morphine-standardized doses are used in clinical practice and research to account for molecular potency. Ninety milligrams of morphine equivalents (MME) per day are considered a "high dose" risk threshold in guidelines, laws, and by payers. Although ubiquitously cited, the "CDC definition" of daily MME lacks a clearly defined denominator. Our objective was to assess denominator-dependency on "high dose" classification across competing definitions. METHODS To identify definitional variants, we reviewed literature and electronic prescribing tools, yielding 4 unique definitions. Using Prescription Drug Monitoring Programs data (July to September 2018), we conducted a population-based cohort study of 3,916,461 patients receiving outpatient opioid analgesics in California (CA) and Florida (FL). The binary outcome was whether patients were deemed "high dose" (>90 MME/d) compared across 4 definitions. We calculated I2 for heterogeneity attributable to the definition. RESULTS Among 9,436,640 prescriptions, 42% overlapped, which led denominator definitions to impact daily MME values. Across definitions, average daily MME varied 3-fold (range: 17 to 52 [CA] and 23 to 65 mg [FL]). Across definitions, prevalence of "high dose" individuals ranged 5.9% to 14.2% (FL) and 3.5% to 10.3% (CA). Definitional variation alone would impact a hypothetical surveillance study trying to establish how much more "high dose" prescribing was present in FL than CA: from 39% to 84% more. Meta-analyses revealed strong heterogeneity (I2 range: 86% to 99%). In sensitivity analysis, including unit interval 90.0 to 90.9 increased "high dose" population fraction by 15%. DISCUSSION While 90 MME may have cautionary mnemonic benefits, without harmonization of calculation, its utility is limited. Comparison between studies using daily MME requires explicit attention to definitional variation.
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Affiliation(s)
| | - Yanning Wang
- Department of Health Outcomes & Biomedical Informatics, University of Florida College of Medicine, Gainesville, FL
| | - Jungjun Bae
- Institute for Pharmaceutical Outcomes & Policy
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
| | - Alan C. Kinlaw
- Cecil G. Sheps Center for Health Services Research
- Division of Pharmaceutical Outcomes and Policy, University of North Carolina School of Pharmacy
| | - Brooke A. Chidgey
- UNC Hospitals Pain Management Center, University of North Carolina at Chapel Hill
- Department of Anesthesiology, University of North Carolina School of Medicine, Chapel Hill, NC
| | | | - Chris Delcher
- Institute for Pharmaceutical Outcomes & Policy
- Department of Pharmacy Practice and Science, University of Kentucky College of Pharmacy, Lexington, KY
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6
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Reducing the use of opioids by patients with chronic pain: an effectiveness study with long-term follow-up. Pain 2021; 161:509-519. [PMID: 31764391 DOI: 10.1097/j.pain.0000000000001763] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study addresses the problem of long-term opioid use by chronic pain patients. The study involved a secondary analysis of unanalyzed data from a published study of 2 versions of cognitive-behavioural therapy-based interdisciplinary treatment for chronic pain. In this study, we examined whether the use of opioids by 140 chronic pain patients could be ceased sustainably over 12 months after participation in the comprehensive interdisciplinary pain management program aimed at enhancing pain self-management. On admission to the treatment, there were no significant differences between those patients taking or not taking opioids on usual pain, pain interference in daily activities, pain-related disability, depression severity, as well as in pain cognitions. After the treatment, the use of opioids was significantly reduced, both in numbers taking any and in mean doses, and these gains were maintained over the 12-month follow-up. Finally, cessation of opioids during treatment was associated with more substantial and consistent improvements in usual pain, depression severity, pain interference, pain-related disability, and pain cognitions, relative to those who reduced their opioids but did not cease them. These findings support the idea of using training in pain self-management strategies as a viable alternative to long-term opioid use by patients with chronic pain.
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7
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Sud A, Armas A, Cunningham H, Tracy S, Foat K, Persaud N, Hosseiny F, Hyland S, Lowe L, Zlahtic E, Murti R, Derue H, Birnbaum I, Bonin K, Upshur R, Nelson MLA. Multidisciplinary care for opioid dose reduction in patients with chronic non-cancer pain: A systematic realist review. PLoS One 2020; 15:e0236419. [PMID: 32716982 PMCID: PMC7384622 DOI: 10.1371/journal.pone.0236419] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 07/06/2020] [Indexed: 11/26/2022] Open
Abstract
CONTEXT Opioid related deaths are at epidemic levels in many developed nations globally. Concerns about the contribution of prescribed opioids, and particularly high-dose opioids, continue to mount as do initiatives to reduce prescribing. Evidence around opioid tapering, which can be challenging and potentially hazardous, is not well developed. A recent national guideline has recognized this and recommended referral to multidisciplinary care for challenging cases of opioid tapering. However, multidisciplinary care for opioid tapering is not well understood or defined. OBJECTIVE Identify the existing literature on any multidisciplinary care programs that evaluate impact on opioid use, synthesize how these programs work and clarify whom they benefit. STUDY DESIGN Systematic rapid realist review. DATASET Bibliographic databases (MEDLINE, EMBASE, CINAHL, PsycINFO, Cochrane Library), grey literature, reference hand search and formal expert consultation. RESULTS 95 studies were identified. 75% of the programs were from the United States and the majority (n = 62) were published after 2000. A minority (n = 23) of programs reported on >12 month opioid use outcomes. There were three necessary but insufficient mechanisms common to all programs: pain relief, behavior change and active medication management. Programs that did not include a combination of all three mechanisms did not result in opioid dose reductions. A concerning 20-40% of subjects resumed opioid use within one year of program completion. CONCLUSIONS Providing alternative analgesia is insufficient for reducing opioid doses. Even high quality primary care multidisciplinary care programs do not reduce prescribed opioid use unless there is active medication management accomplished by changing the primary opioid prescriber. Rates of return to use of opioids from these programs are very concerning in the current context of a highly potent and lethal street drug supply. This contextual factor may be powerful enough to undermine the modest benefits of opioid dose reduction via multidisciplinary care.
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Affiliation(s)
- Abhimanyu Sud
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Alana Armas
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Heather Cunningham
- Gerstein Science Information Centre, University of Toronto, Toronto, Ontario, Canada
| | - Shawn Tracy
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
| | - Kirk Foat
- Independent Researcher, London, Ontario, Canada
| | - Navindra Persaud
- Department of Family and Community Medicine, St. Michael’s Hospital, Toronto, Ontario, Canada
- MAP Centre for Urban Health Solutions, Keenan Research Centre, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Fardous Hosseiny
- Canadian Mental Health Association National, Toronto, Ontario, Canada
| | - Sylvia Hyland
- Institute for Safe Medication Practices Canada, Toronto, Ontario, Canada
| | - Leyna Lowe
- Canadian Mental Health Association National, Toronto, Ontario, Canada
| | - Erin Zlahtic
- Kinesiology, Western University, London, Ontario, Canada
| | - Rhea Murti
- Arts & Science, McMaster University, Hamilton, Ontario, Canada
| | - Hannah Derue
- Psychology, University of Guelph-Humber, Toronto, Ontario, Canada
| | - Ilana Birnbaum
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Katija Bonin
- Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ross Upshur
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Michelle L. A. Nelson
- Bridgepoint Collaboratory for Research and Innovation, Lunenfeld-Tanenbaum Research Institute, Sinai Health System, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
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8
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Influence of placebo analgesia in pharmacological treatment of pain. FUTURE DRUG DISCOVERY 2020. [DOI: 10.4155/fdd-2019-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Placebo effects are relevant to routine clinical practice, even if no traditional placebo is given. The healthcare encounter is often rich in factors that may affect both placebo and nocebo components of care, therefore, an opportunity exists to target elements of this encounter to enhance clinical effectiveness. This review will outline the contemporary conceptualizations of placebo and the mechanisms of placebo effects. Specifically, how to harness these placebo effects in clinical practice. Currently, these include optimizing the therapeutic context, shaping of expectations, assessing belief structures and framing information delivery, utilization of conditioning regimes to augment drug response or reduce overall drug dosing and the potential integration of traditional placebos with scientifically proven treatments to augment care.
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Lewis GN, Bean D, Mowat R. How Have Chronic Pain Management Programs Progressed? A Mapping Review. Pain Pract 2019; 19:767-784. [DOI: 10.1111/papr.12805] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2019] [Revised: 05/09/2019] [Accepted: 06/04/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Gwyn N. Lewis
- Health and Rehabilitation Research Institute Auckland University of Technology AucklandNew Zealand
| | - Debbie Bean
- Department of Psychological Medicine University of Auckland AucklandNew Zealand
- The Auckland Regional Pain Service Auckland District Health Board AucklandNew Zealand
| | - Rebecca Mowat
- Toi Ohomai Institute of Technology Tauranga New Zealand
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10
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Selecting the Appropriate Patient for Opioid Therapy: Risk Assessment and Treatment Strategies for Gynecologic Pain. Clin Obstet Gynecol 2019; 62:48-58. [DOI: 10.1097/grf.0000000000000411] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Bienek N, Maier C, Kaisler M, Michel-Lauter B, Schwarzer A, Meyer-Frießem CH. Intensity of Withdrawal Symptoms During Opioid Taper in Patients with Chronic Pain—Individualized or Fixed Starting Dosage? PAIN MEDICINE 2019; 20:2438-2449. [DOI: 10.1093/pm/pny320] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AbstractObjectiveControlled opioid withdrawal is recommended for patients with chronic noncancer pain (CNCP) with insufficient pain reduction or intolerable side effects while on opioid treatment. Few studies have investigated the management of opioid withdrawal (OW). Most common are protocols with an individualized starting dosage (ISD), calculated from the last opioid intake. After two cases of overdose, we introduced a novel withdrawal protocol using a low fixed starting dosage (FSD) for safety reasons. The present study compares the intensity of withdrawal symptoms using the Subjective Opioid Withdrawal Scale (SOWS) and incidences of serious adverse events (SAE) and dropouts in each taper schedule in 195 CNCP patients with OW in an inpatient facility.MethodsTwo protocols were compared: FSD (2014–2016): N = 68, starting dose: 90 mg morphine/d; and ISD (2010–2014): N = 127, starting dose: 70% of the patient’s daily morphine equivalent dose (MED). Outcome criteria: primary: mean daily SOWS score during the first 10 days (16 questions, daily score 0–64); secondary: change in pain intensity on a numeric rating scale (0–10), rate of dropouts and SAEs. Statistics: Student test, Mann-Whitney U test, chi-square test, analysis of variance, P < 0.05.ResultsThe mean daily SOWS score was lower in the FSD group (14.9 ± 9.4 vs 16.1 ± 10, P < 0.05) due to a lower rate of high-intensity withdrawal symptoms (12.4% vs 17.6%, P < 0.01), particularly in patients on >180 mg MED (9.7% vs 18.4%, P < 0.01). Pain intensity decreased after withdrawal, and the incidence of SAEs and dropouts was low in both groups.ConclusionsThe FSD protocol provides a lesser burden of withdrawal symptoms and equal patient safety. It can be recommended for OW in CNCP patients.
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Affiliation(s)
- Natalia Bienek
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology and Intensive Care, Klinikum Dortmund, Dortmund, Germany
| | | | | | | | | | - Christine H Meyer-Frießem
- Department of Pain Medicine, Ruhr-University Bochum
- Department of Anaesthesiology, Intensive Care Medicine, Palliative Care Medicine and Pain Management, Medical Faculty of Ruhr-University Bochum, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil gGmbH Bochum, Bochum, Germany
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12
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Fishbain DA, Pulikal A. Does Opioid Tapering in Chronic Pain Patients Result in Improved Pain or Same Pain vs Increased Pain at Taper Completion? A Structured Evidence-Based Systematic Review. PAIN MEDICINE 2018; 20:2179-2197. [DOI: 10.1093/pm/pny231] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abstract
Objective
To support or refute the hypothesis that opioid tapering in chronic pain patients (CPPs) improves pain or maintains the same pain level by taper completion but does not increase pain.
Methods
Of 364 references, 20 fulfilled inclusion/exclusion criteria. These studies were type 3 and 4 (not controlled) but reported pre/post-taper pain levels. Characteristics of the studies were abstracted into tabular form for numerical analysis. Studies were rated independently by two reviewers for quality. The percentage of studies supporting the above hypothesis was determined.
Results
No studies had a rejection quality score. Combining all studies, 2,109 CPPs were tapered. Eighty percent of the studies reported that by taper completion pain had improved. Of these, 81.25% demonstrated this statistically. In 15% of the studies, pain was the same by taper completion. One study reported that by taper completion, 97% of the CPPs had improved or the same pain, but CPPs had worse pain in 3%. As such, 100% of the studies supported the hypothesis. Applying the Agency for Health Care Policy and Research Levels of Evidence Guidelines to this result produced an A consistency rating.
Conclusions
There is consistent type 3 and 4 study evidence that opioid tapering in CPPs reduces pain or maintains the same level of pain. However, these studies represented lower levels of evidence and were not designed to test the hypothesis, with the evidence being marginal in quality with large amounts of missing data. These results then primarily reveal the need for controlled studies (type 2) to address this hypothesis.
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Affiliation(s)
- David A Fishbain
- Departments of Psychiatry
- Departments of Neurological Surgery
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
| | - Aditya Pulikal
- Departments of Anesthesiology, Miller School of Medicine at the University of Miami, Miami, Florida, USA
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13
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Tseng KS. Considerations in 2017–2018 for the Use of Opioids in Non-terminal Pain. CURRENT ANESTHESIOLOGY REPORTS 2018. [DOI: 10.1007/s40140-018-0289-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Ranapurwala SI, Naumann RB, Austin AE, Dasgupta N, Marshall SW. Methodologic limitations of prescription opioid safety research and recommendations for improving the evidence base. Pharmacoepidemiol Drug Saf 2018; 28:4-12. [PMID: 29862602 DOI: 10.1002/pds.4564] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 03/29/2018] [Accepted: 05/03/2018] [Indexed: 12/26/2022]
Abstract
PURPOSE The ongoing opioid epidemic has claimed more than a quarter million Americans' lives over the past 15 years. The epidemic began with an escalation of prescription opioid deaths and has now evolved to include secondary waves of illicit heroin and fentanyl deaths, while the deaths due to prescription opioid overdoses are still increasing. In response, the Centers for Disease Control and Prevention (CDC) moved to limit opioid prescribing with the release of opioid prescribing guidelines for chronic noncancer pain in March 2016. The guidelines represent a logical and timely federal response to this growing crisis. However, CDC acknowledged that the evidence base linking opioid prescribing to opioid use disorders and overdose was grades 3 and 4. METHODS Motivated by the need to strengthen the evidence base, this review details limitations of the opioid safety studies cited in the CDC guidelines with a focus on methodological limitations related to internal and external validity. RESULTS Internal validity concerns were related to poor confounding control, variable misclassification, selection bias, competing risks, and potential competing interventions. External validity concerns arose from the use of limited source populations, historical data (in a fast-changing epidemic), and issues with handling of cancer and acute pain patients' data. We provide a nonexhaustive list of 7 recommendations to address these limitations in future opioid safety studies. CONCLUSION Strengthening the opioid safety evidence base will aid any future revisions of the CDC guidelines and enhance their prevention impact.
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Affiliation(s)
- Shabbar I Ranapurwala
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Rebecca B Naumann
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Anna E Austin
- Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Department of Maternal and Child Health, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Nabarun Dasgupta
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Stephen W Marshall
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.,Injury Prevention Research Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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15
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Placebo Effects: Historical and Modern Evaluation. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2018; 139:1-27. [DOI: 10.1016/bs.irn.2018.07.010] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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16
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Guildford BJ, Daly-Eichenhardt A, Hill B, Sanderson K, McCracken LM. Analgesic reduction during an interdisciplinary pain management programme: treatment effects and processes of change. Br J Pain 2017; 12:72-86. [PMID: 29796259 DOI: 10.1177/2049463717734016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Long-term use of opioid medication is associated with a host of negative effects on health and quality of life. Guidelines state that people with chronic pain taking high doses of opioids without benefit should be supported to discontinue them. Little research has investigated psychological processes associated with analgesic use and tapering. This study investigated (1) analgesic use pre- and post-participation in an interdisciplinary pain management programme and its relationship to functioning and (2) psychological processes associated with analgesic use. Opioid use was associated with poorer functioning at baseline. Participating in an interdisciplinary pain management programme was associated with reductions in opioid dose and number of classes of analgesics used. Reductions in analgesic use were associated with improvements in functioning. Psychological inflexibility was associated with using higher doses of opioid medication and with using a greater number of classes of analgesics. Psychological flexibility appears relevant in explaining analgesic use. Future research could focus on targeting this process to improve tapering outcomes.
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Affiliation(s)
- Beth J Guildford
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,NIHR Maudsley Biomedical Research Centre, King's Health Partners, London, UK
| | - Aisling Daly-Eichenhardt
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Bethany Hill
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Karen Sanderson
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lance M McCracken
- INPUT Pain Management Unit, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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17
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18
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Effectiveness of psychological interventions for chronic pain on health care use and work absence. Pain 2016; 157:777-785. [DOI: 10.1097/j.pain.0000000000000434] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. MMWR Recomm Rep 2016; 65:1-49. [PMID: 26987082 DOI: 10.15585/mmwr.rr6501e1] [Citation(s) in RCA: 1991] [Impact Index Per Article: 248.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This guideline provides recommendations for primary care clinicians who are prescribing opioids for chronic pain outside of active cancer treatment, palliative care, and end-of-life care. The guideline addresses 1) when to initiate or continue opioids for chronic pain; 2) opioid selection, dosage, duration, follow-up, and discontinuation; and 3) assessing risk and addressing harms of opioid use. CDC developed the guideline using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, and recommendations are made on the basis of a systematic review of the scientific evidence while considering benefits and harms, values and preferences, and resource allocation. CDC obtained input from experts, stakeholders, the public, peer reviewers, and a federally chartered advisory committee. It is important that patients receive appropriate pain treatment with careful consideration of the benefits and risks of treatment options. This guideline is intended to improve communication between clinicians and patients about the risks and benefits of opioid therapy for chronic pain, improve the safety and effectiveness of pain treatment, and reduce the risks associated with long-term opioid therapy, including opioid use disorder, overdose, and death. CDC has provided a checklist for prescribing opioids for chronic pain (http://stacks.cdc.gov/view/cdc/38025) as well as a website (http://www.cdc.gov/drugoverdose/prescribingresources.html) with additional tools to guide clinicians in implementing the recommendations.
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Affiliation(s)
- Deborah Dowell
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, CDC, Atlanta, Georgia
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20
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Berna C, Kulich RJ, Rathmell JP. Tapering Long-term Opioid Therapy in Chronic Noncancer Pain: Evidence and Recommendations for Everyday Practice. Mayo Clin Proc 2015; 90:828-42. [PMID: 26046416 DOI: 10.1016/j.mayocp.2015.04.003] [Citation(s) in RCA: 148] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2015] [Revised: 03/31/2015] [Accepted: 04/07/2015] [Indexed: 11/22/2022]
Abstract
Increasing concern about the risks and limited evidence supporting the therapeutic benefit of long-term opioid therapy for chronic noncancer pain are leading prescribers to consider discontinuing the use of opioids. In addition to overt addiction or diversion, the presence of adverse effects, diminishing analgesia, reduced function and quality of life, or the absence of progress toward functional goals can justify an attempt at weaning patients from long-term opioid therapy. However, discontinuing opioid therapy is often hindered by patients' psychiatric comorbidities and poor coping skills, as well as the lack of formal guidelines for the prescribers. The aim of this article is to review the existing literature and formulate recommendations for practitioners aiming to discontinue long-term opioid therapy. Specifically, this review aims to answer the following questions: What is an optimal opioid tapering regimen? How can the risks involved in a taper be managed? What are the alternatives to an opioid taper? A PubMed literature search was conducted using the keywords chronic pain combined with opioid withdrawal, taper, wean and detoxification. Six hundred ninety-five documents were identified and screened; 117 were deemed directly relevant and are included. On the base of this literature review, this article proposes evidence-based recommendations and expert-based suggestions for clinical practice. Furthermore, areas of lack of evidence are identified, providing opportunities for further research.
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Affiliation(s)
- Chantal Berna
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA
| | - Ronald J Kulich
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA; Tufts University School of Dental Medicine, Boston, MA
| | - James P Rathmell
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.
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21
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Morley S, Williams A. New Developments in the Psychological Management of Chronic Pain. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2015; 60:168-75. [PMID: 26174216 PMCID: PMC4459243 DOI: 10.1177/070674371506000403] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 12/01/2014] [Indexed: 01/03/2023]
Abstract
After reviewing how psychological treatment for chronic pain comes to have its current form, and summarizing treatment effectiveness, we explore several areas of development. We describe third wave therapies, such as mindfulness; we discuss what the research literature aggregated can tell us about what trials are more useful to conduct; and we outline some areas of promise and some failures to deliver on promise. The article is drawn together using the framework of the normal psychology of pain, identifying some of its most important implications for improving life for people with chronic pain.
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Affiliation(s)
- Stephen Morley
- Professor of Clinical Psychology, University of Leeds, Leeds, England
| | - Amanda Williams
- Reader in Clinical Health Psychology, University College, London, England
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22
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Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med 2015; 162:276-86. [PMID: 25581257 DOI: 10.7326/m14-2559] [Citation(s) in RCA: 1085] [Impact Index Per Article: 120.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Increases in prescriptions of opioid medications for chronic pain have been accompanied by increases in opioid overdoses, abuse, and other harms and uncertainty about long-term effectiveness. PURPOSE To evaluate evidence on the effectiveness and harms of long-term (>3 months) opioid therapy for chronic pain in adults. DATA SOURCES MEDLINE, the Cochrane Central Register of Controlled Trials, the Cochrane Database of Systematic Reviews, PsycINFO, and CINAHL (January 2008 through August 2014); relevant studies from a prior review; reference lists; and ClinicalTrials.gov. STUDY SELECTION Randomized trials and observational studies that involved adults with chronic pain who were prescribed long-term opioid therapy and that evaluated opioid therapy versus placebo, no opioid, or nonopioid therapy; different opioid dosing strategies; or risk mitigation strategies. DATA EXTRACTION Dual extraction and quality assessment. DATA SYNTHESIS No study of opioid therapy versus no opioid therapy evaluated long-term (>1 year) outcomes related to pain, function, quality of life, opioid abuse, or addiction. Good- and fair-quality observational studies suggest that opioid therapy for chronic pain is associated with increased risk for overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction, although there are few studies for each of these outcomes; for some harms, higher doses are associated with increased risk. Evidence on the effectiveness and harms of different opioid dosing and risk mitigation strategies is limited. LIMITATIONS Non-English-language articles were excluded, meta-analysis could not be done, and publication bias could not be assessed. No placebo-controlled trials met inclusion criteria, evidence was lacking for many comparisons and outcomes, and observational studies were limited in their ability to address potential confounding. CONCLUSION Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose-dependent risk for serious harms. PRIMARY FUNDING SOURCE Agency for Healthcare Research and Quality.
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Affiliation(s)
- Roger Chou
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Judith A. Turner
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Emily B. Devine
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Ryan N. Hansen
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Sean D. Sullivan
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Ian Blazina
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Tracy Dana
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Christina Bougatsos
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
| | - Richard A. Deyo
- From Oregon Health & Science University, Portland, Oregon, and University of Washington, Seattle, Washington
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23
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Nicholas MK, McGuire BE, Asghari A. A 2-Item Short Form of the Pain Self-Efficacy Questionnaire: Development and Psychometric Evaluation of PSEQ-2. THE JOURNAL OF PAIN 2015; 16:153-63. [DOI: 10.1016/j.jpain.2014.11.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Revised: 10/23/2014] [Accepted: 11/03/2014] [Indexed: 10/24/2022]
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24
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Von Korff M. Opioids for chronic musculoskeletal pain: putting patient safety first. Pain 2013; 154:2583-2585. [PMID: 24076163 PMCID: PMC4036622 DOI: 10.1016/j.pain.2013.09.017] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2013] [Revised: 09/12/2013] [Accepted: 09/17/2013] [Indexed: 11/13/2022]
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25
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Abstract
Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed.
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Affiliation(s)
- Michael R Von Korff
- Group Health Research Institute, 1730 Minor Ave., Suite 1600, Seattle, WA 98101, USA.
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26
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Opioid cessation and multidimensional outcomes after interdisciplinary chronic pain treatment. Clin J Pain 2013; 29:109-17. [PMID: 22751033 DOI: 10.1097/ajp.0b013e3182579935] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVES Although the efficacy of interdisciplinary treatment for chronic noncancer pain has been well-established in the literature, there is limited research examining interdisciplinary programs that require opioid cessation. As the long-term use of opioid analgesics remains controversial, further investigation is warranted. The aim of this study was to evaluate the associations between opioid cessation and subsequent multidomain treatment outcomes among veterans admitted to a pain rehabilitation program at a large Veterans Affairs tertiary care hospital in the southeastern United States. METHODS A retrospective design examined the medical records of 705 consecutive admissions comparing those using opioids at admission with those who were not. Participants taking opioids agreed to taper off of these medications using a "pain cocktail" approach; otherwise patients received identical treatment. Outcome measures were administered at program admission and discharge. RESULTS Repeated measures analyses were used to compare responses across time. Those who completed the program (n=600) demonstrated improvement in all outcome measures from admission to discharge, and the opioid group improved as much or more than the nonopioid group on all measures despite opioid cessation during treatment. DISCUSSION Results indicated that both groups experienced significant improvement on outcome measures, and that opioid analgesic use at admission had no discernible impact on treatment outcome in this large sample of veterans with moderate to severe chronic pain syndrome. The clinical implications of these findings for long-term chronic pain treatment, in light of the risks associated with opioid analgesics, are discussed.
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27
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Mercadante S. Methadone in cancer pain. Eur J Pain 2012; 1:77-83; discussion 84-5. [PMID: 15102407 DOI: 10.1016/s1090-3801(97)90064-1] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/1997] [Accepted: 06/17/1997] [Indexed: 10/26/2022]
Abstract
Methadone is often considered as a second-choice drug alternative to morphine in cancer pain treatment. A lack of information regarding methadone's pharmacokinetic/pharmacodynamic relationships has contributed to limitation in its use in analgesic treatments. However, it has been recently re-evaluated in light of better knowledge of its pharmacological characteristics and wider experience. Concern about the safety of methadone therapy arising because of its long and unpredictable half-life should not deter clinicians from its appropriate use. Methadone is a very useful drug in cancer pain because of its low cost, lack of known metabolites, high oral bioavailability, rapid onset and time to peak analgesic effect, and the long duration of activity which allows for longer intervals between doses. Moreover, methadone has been demonstrated to have a high receptor reserve and to exert some NMDA receptor antagonist effect. A shift from one opioid to methadone is recommended when the side-effect/analgesic balance is unfavourable, as symmetrical patterns of cross-tolerance of opioid agonists have been demonstrated. Different approaches, including the oral PCA, have been proposed to circumvent problems related to its pharmacokinetic properties.
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Affiliation(s)
- S Mercadante
- Pain Relief and Palliative Care, SAMOT, Palermo, Italy
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28
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Nicholas MK. The pain self-efficacy questionnaire: Taking pain into account. Eur J Pain 2012; 11:153-63. [PMID: 16446108 DOI: 10.1016/j.ejpain.2005.12.008] [Citation(s) in RCA: 1019] [Impact Index Per Article: 84.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Revised: 12/12/2005] [Accepted: 12/14/2005] [Indexed: 11/20/2022]
Abstract
Self-efficacy beliefs in people with chronic pain have been assessed either by reference to confidence in ability to perform specific tasks or to confidence in performing more generalised constructs like coping with pain. Both approaches reflect aspects of the original conceptualisations of self-efficacy and both have proved useful, but it is noteworthy that confidence in performing activities in the context of pain is rarely addressed. An important element in the original formulations of self-efficacy referred to persistence in the face of obstacles and aversive experiences. In this context, self-efficacy beliefs for people experiencing chronic pain might be expected to incorporate not just the expectation that a person could perform a particular behaviour or task, but also their confidence in being able to do it despite their pain. This aspect of the self-efficacy construct has been included in a measure for people with chronic pain, the Pain Self-Efficacy Questionnaire (PSEQ). The accumulated evidence from a number of published studies and a confirmatory analysis with a large cohort of heterogeneous chronic pain patients attending a pain management program provide support for the PSEQ's original psychometric properties developed with a sample of chronic low back pain patients. The importance of taking the context of pain into account in the assessment of self-efficacy beliefs in pain populations and the ways in which this measure can be used to improve the assessment of people experiencing chronic pain, before and after treatment, are examined.
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Affiliation(s)
- Michael K Nicholas
- Pain Management and Research Centre, University of Sydney at Royal North Shore Hospital, St. Leonards, Sydney, NSW 2065, Australia.
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29
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Nilsen HK, Stiles TC, Landrø NI, Fors EA, Kaasa S, Borchgrevink PC. Patients with problematic opioid use can be weaned from codeine without pain escalation. Acta Anaesthesiol Scand 2010; 54:571-9. [PMID: 19919582 DOI: 10.1111/j.1399-6576.2009.02164.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Brief treatments for chronic non-malignant pain patients with problematic opioid use are warranted. The aims of the present study were to investigate (1) whether it is possible to withdraw codeine use in such patients with a brief cognitive-behavioural therapy (CBT), (2) whether this could be done without pain escalation and reduction in quality of life and (3) to explore the effects of codeine reduction on neurocognitive functioning. METHODS Eleven patients using codeine daily corresponding to 40-100 mg morphine were included. Two specifically trained physicians treated the patients with six CBT sessions, tapering codeine gradually within 8 weeks. Codeine use, pain intensity, quality of life and neuropsychological functioning were assessed at pre-treatment to the 3-month follow-up. RESULTS Codeine use was significantly reduced from mean 237 mg [standard deviation (SD) 65] pre-treatment to 45 mg (SD 66) post-treatment and to 48 mg (SD 65) at follow-up without significant pain escalation or reductions in quality of life. Moreover, neuropsychological functioning improved significantly on some tests, while others remained unchanged. CONCLUSION The promising findings of codeine reduction in this weaning therapy programme for pain patients with problematic opioid use should be further evaluated in a larger randomized control trial comparing this brief CBT with both another brief treatment and attention placebo condition.
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Affiliation(s)
- H K Nilsen
- Pain and Palliation Research Group, Institute of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway.
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30
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Wong M, Rietzschel J, Mulherin D, David C. Evaluation of a multidisciplinary outpatient pain management programme based at a community hospital. Musculoskeletal Care 2009; 7:106-120. [PMID: 19051202 DOI: 10.1002/msc.147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE To evaluate a multidisciplinary cognitive behavioural therapy pain management programme (PMP) based at a small community hospital. METHODS Patients attending the PMP were assessed at three intervals (pre-training, and 18 and 44 weeks post-training) using a set of seven questionnaires. Information about their general practitioner (GP) and consultant visits was recorded at pre-training and final follow-up visits. Questionnaires were completed and additional personal information recorded before patients attended their appointments. RESULTS Between 1997 and 2006, 163 patients completed at least six sessions out of the eight-week programme. Of these, 70 who had completed at least one questionnaire outcome measure at the three assessment intervals, and 83 who had provided information on their GP and consultant visits at pre-training and final follow-up, were included in the analyses. The results showed that patients reported being more confident in coping with their pain (pain self-efficacy questionnaire) at 18 weeks post-training and their improvement was sustained at the final follow-up. They were significantly less depressed (hospital and anxiety depression scale [HADS]) and reported a large improvement in their quality of life (modified patient generated index) at the final follow-up. They also reported a significant reduction in pain-related GP and consultant visits at their final follow-up. Although there were improvements in the Tampa scale of kinesiophobia, anxiety (HADS-Anx) and sickness impact profile scores, these were not statistically significant. CONCLUSION The result of the evaluation indicated that this PMP, delivered in a community hospital setting, made some significant differences to patients with intractable chronic pain conditions.
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Affiliation(s)
- Mei Wong
- Department of Physical Health Psychology, Cannock Chase Hospital, UK.
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31
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Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. THE JOURNAL OF PAIN 2009; 10:113-30. [PMID: 19187889 DOI: 10.1016/j.jpain.2008.10.008] [Citation(s) in RCA: 1444] [Impact Index Per Article: 96.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2008] [Revised: 10/28/2008] [Accepted: 10/28/2008] [Indexed: 02/07/2023]
Abstract
UNLABELLED Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related policies. PERSPECTIVE Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
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Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research Gaps on Use of Opioids for Chronic Noncancer Pain: Findings From a Review of the Evidence for an American Pain Society and American Academy of Pain Medicine Clinical Practice Guideline. THE JOURNAL OF PAIN 2009; 10:147-59. [DOI: 10.1016/j.jpain.2008.10.007] [Citation(s) in RCA: 214] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Revised: 10/03/2008] [Accepted: 10/28/2008] [Indexed: 12/26/2022]
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Younger J, Barelka P, Carroll I, Kaplan K, Chu L, Prasad R, Gaeta R, Mackey S. Reduced cold pain tolerance in chronic pain patients following opioid detoxification. PAIN MEDICINE (MALDEN, MASS.) 2008; 9:1158-63. [PMID: 18564998 PMCID: PMC2751584 DOI: 10.1111/j.1526-4637.2008.00475.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE One potential consequence of chronic opioid analgesic administration is a paradoxical increase of pain sensitivity over time. Little scientific attention has been given to how cessation of opioid medication affects the hyperalgesic state. In this study, we examined the effects of opioid tapering on pain sensitivity in chronic pain patients. DESIGN Twelve chronic pain patients on long-term opioid analgesic treatment were observed in a 7- to 14-day inpatient pain rehabilitation program, with cold pain tolerance assessed at admission and discharge. The majority of participants were completely withdrawn from their opioids during their stay. OUTCOME MEASURES We hypothesized that those patients with the greatest reduction in daily opioid use would show the greatest increases in pain tolerance, as assessed by a cold pressor task. RESULTS A linear regression revealed that the amount of opioid medication withdrawn was a significant predictor of pain tolerance changes, but not in the direction hypothesized. Greater opioid reduction was associated with decreased pain tolerance. This reduction of pain tolerance was not associated with opioid withdrawal symptoms or changes in general pain. CONCLUSIONS These findings suggest that the withdrawal of opioids in a chronic pain sample leads to an acute increase in pain sensitivity.
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Affiliation(s)
- Jarred Younger
- Stanford University School of Medicine, Department of Anesthesia, Division of Pain Management, Palo Alto, California 94304-1573, USA.
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Lim HS, Chen PP, Wong TCM, Gin T, Wong E, Chan ISF, Chu J. Validation of the Chinese Version of Pain Self-Efficacy Questionnaire. Anesth Analg 2007; 104:918-23. [PMID: 17377107 DOI: 10.1213/01.ane.0000255731.24092.a5] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND Self-efficacy is a person's belief in his or her ability to perform a certain behavior that achieves a desired outcome. Belief in self-efficacy influences the use of pain-coping strategies, physical and psychological function, and rehabilitation outcome in chronic pain patients. We conducted this prospective study to validate the psychometric properties of a Chinese version of the Pain Self-Efficacy Questionnaire (PSEQ-HK). METHODS A previously translated PSEQ-HK was evaluated with the author's consent. Forward-backward translation was conducted, followed by critical appraisal by an expert panel. Reliability was examined by completing the PSEQ-HK twice over a 1-wk interval. One-hundred-twenty Chinese patients with chronic nonmalignant pain were asked to self-complete a set of health-related instruments in Chinese: Numeric Pain Rating Scale, Hospital Anxiety and Depression Scale, Roland-Morris Disability Questionnaire, Pain Catastrophizing Scale, and Medical Outcome Study Short-Form 36 (SF36) Health Survey. RESULTS PSEQ-HK had good retest reliability (intraclass correlation coefficient 0.75) and high internal consistency (Cronbach's alpha 0.93). Exploratory factor analysis showed a one-factor model that accounted for 61% of the total variance, with minimal factor loading of 0.69. It was significantly correlated with the Hospital Anxiety and Depression Scale, Pain Catastrophizing Scale, and five domains of SF36 (bodily pain, vitality, social functioning, role emotion, and mental health). Moderate correlations were observed with Roland-Morris Disability Questionnaire and two domains of SF36 (role physical, general health). It had no correlation with pain score and medication use. CONCLUSIONS PSEQ-HK is a reliable Chinese clinical assessment tool with satisfactory psychometric properties. Our results provided preliminary support for the construct validity of PSEQ-HK in a heterogeneous Chinese population with chronic nonmalignant pain.
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Affiliation(s)
- Huey S Lim
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Hong Kong, China.
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Nicholas MK, Molloy AR, Brooker C. Using opioids with persisting noncancer pain: a biopsychosocial perspective. Clin J Pain 2006; 22:137-46. [PMID: 16428947 DOI: 10.1097/01.ajp.0000154046.22532.fe] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Despite the growing use of opioids for persisting noncancer pain, evidence for their effectiveness is limited, especially in relation to functional outcomes. Guidelines have been developed for prescribers, but their utility is untested. This review examines the use of opioids in this population from a biopsychosocial perspective and makes a number of recommendations. DATA SOURCES Published comparison studies and reviews of oral opioids in chronic noncancer pain, as well as 5 published guidelines for the prescription of opioids and systematic reviews of cognitive-behavioral pain management programs. METHODS Outcomes of the opioid comparison studies were reviewed and compared to those achieved by pain management programs. CONCLUSIONS The available evidence indicates that by themselves, oral opioids generally achieve only modest reductions in pain levels in patients with chronic noncancer pain. Functional outcomes are inconsistent across studies. There are questions about the timing of their use and patient selection. There are risks in trials of opioids only after other conservative interventions have been tried unsuccessfully. Also, in some patients, ongoing use of opioids risks repeated over-doing of pain-generating activities and reinforcing escape/avoidance responses that promote disability. These risks may be lessened by assessment of current use of pain self-management strategies among potential candidates for opioids. This offers advantages in promoting collaborative management of persisting pain as well as better pain and functional outcomes. In this view, opioids may be considered as one possible element of a management plan rather than the primary treatment.
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Affiliation(s)
- Michael K Nicholas
- University of Sydney Pain Management and Research Centre, Royal North Shore Hospital, St. Leonards, Australia.
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Savage SR, Joranson DE, Covington EC, Schnoll SH, Heit HA, Gilson AM. Definitions related to the medical use of opioids: evolution towards universal agreement. J Pain Symptom Manage 2003; 26:655-67. [PMID: 12850648 DOI: 10.1016/s0885-3924(03)00219-7] [Citation(s) in RCA: 125] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Misunderstandings regarding the nature and occurrence of addiction have historically been barriers to the appropriate treatment of pain and have stigmatized the medical use of opioids. This article reviews the evolution of nomenclature related to addiction, presents current scientific understanding of addiction that may help shape universally acceptable terminology, and discusses an integrated effort of pain and addiction professionals to reach consensus on addiction-related terms. The article suggests key principles that may clarify terminology including: clear differentiation of the concepts of addiction and physical dependence, conceptualization of addiction as a multidimensional disease, and use of a label for the phenomenon of addiction that does not include the ambiguous term "dependence." More universal agreement on terminology related to addiction is expected to improve the treatment of both pain and addictive disorders; improve communication between health care providers, regulators, and enforcement agencies; and reduce health care and other societal costs.
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Affiliation(s)
- Seddon R Savage
- Department of Anesthesiology, Dartmouth Medical School, Hanover, New Hampshire, USA
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Affiliation(s)
- B J Collett
- Pain Management Service, University Hospitals of Leicester, Leicester Royal Infirmary, Leicester LE1 5WW, UK
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de C Williams AC, Nicholas MK, Richardson PH, Pither CE, Fernandes J. Generalizing from a controlled trial: the effects of patient preference versus randomization on the outcome of inpatient versus outpatient chronic pain management. Pain 1999; 83:57-65. [PMID: 10506672 DOI: 10.1016/s0304-3959(99)00074-3] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Patients accepting randomization in a randomized controlled trial (RCT) may not be representative of the clinical population from which they are drawn, calling into question the generalizability of study findings. Comparison of randomized and non-randomized inpatient and outpatient samples at baseline and in treatment outcomes up to one year was made to determine whether the findings of the RCT generalized to non-randomized patients in the same treatment program. One hundred and twenty one patients with intractable pain, randomized between inpatient, outpatient and waiting list control, were compared with 128 who elected for either inpatient or outpatient treatment. Treatment was a group-based multidisciplinary cognitive-behavioral treatment program aimed at enabling patients to return to more normal function despite persistent pain, delivered to mixed groups of randomized and elective patients, and outcome was measured by physical performance, pain impact on function, mood, and drug use. Agreement to randomization was a function of travelling distance from home to hospital. Non-randomized patients largely resembled their randomized counterparts before and after treatment. In order to indicate the clinical significance of results, analyses were conducted using numbers needed to treat (NNTs). NNTs estimate the number of patients required in the treatment condition for one of them to achieve the specified outcome who would not have achieved it in the comparison condition. Across a range of measures at one month follow-up, comparison of inpatients with outpatients gave NNTs between 2.3 and 7.5, and comparison of inpatients with waiting list controls gave NNTs between 2.3 and 3.6. At one year inpatients showed greater likelihood than outpatients of maintaining these treatment gains.
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Affiliation(s)
- A C de C Williams
- Division of Psychiatry and Psychology, King's, Guy's and St. Thomas' Medical and Dental Schools, University of London, London, UK.
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Kirkpatrick AF, Derasari M, Kovacs PL, Lamb BD, Miller R, Reading A. A protocol-contract for opioid use in patients with chronic pain not due to malignancy. J Clin Anesth 1998; 10:435-43. [PMID: 9702628 DOI: 10.1016/s0952-8180(98)00062-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The legal, psychosocial, and medical factors that we believe have contributed to the success of our protocol-contract in prescribing opioids to patients with chronic pain not due to malignancy are outlined. These factors may be applicable to the treatment of a variety of chronic nonmalignant pain syndromes such as postherpetic neuralgia or human immunodeficiency virus/acquired immunodeficiency syndrome. The intended target audience of this paper is the physician (primary care, chronic pain specialist) who is involved in prescribing opioids for the treatment of chronic, nonmalignant pain.
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Affiliation(s)
- A F Kirkpatrick
- Department of Anesthesiology, University of South Florida College of Medicine, Tampa 33612-4799, USA
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Jensen MP, Turner LR, Turner JA, Romano JM. The use of multiple-item scales for pain intensity measurement in chronic pain patients. Pain 1996; 67:35-40. [PMID: 8895229 DOI: 10.1016/0304-3959(96)03078-3] [Citation(s) in RCA: 172] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
This study examined the relative predictive validities of several measures of pain intensity. Forty chronic pain patients completed 6-14 days worth of hourly pain ratings, which were averaged to obtain a measure of actual average pain intensity. These patients then made ratings, on 101-point numerical rating scales, of worst, least, and usual pain during the previous 2 wks, and of their current pain. A series of correlation coefficients were computed and regression analyses were performed to determine the individual or composite measures that best predicted actual average pain intensity. Consistent with previous research, the best single predictor of actual average pain intensity was patient rating of least pain in the previous 2 wks. Of all possible composites of usual, least, worst, and current pain ratings, the arithmetic mean of least and usual pain had the strongest relationship to actual average pain. The inclusion of ratings of most pain or current pain in any composite score actually weakened the relationship between the composite score and actual average pain intensity. These results suggest that, when clinicians or researchers wish to assess average pain among chronic pain patients, but cannot obtain multiple measures of pain over time, the most valid measure would be the arithmetic mean of patient-recalled least and usual pain.
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Affiliation(s)
- Mark P Jensen
- Department of Rehabilitation Medicine, University of Washington School of Medicine, Seattle, Washington, USA Multidisciplinary Pain Center, University of Washington Medical Center, Seattle, Washington, USA Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, Washington, USA
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de Williams CAC, Richardson PH, Nicholas MK, Pither CE, Harding VR, Ridout KL, Ralphs JA, Richardson IH, Justins DM, Chamberlain JH. Inpatient vs. outpatient pain management: results of a randomised controlled trial. Pain 1996; 66:13-22. [PMID: 8857627 DOI: 10.1016/0304-3959(96)02996-x] [Citation(s) in RCA: 136] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Inpatient and outpatient cognitive behavioural pain management programmes for mixed chronic pain patients were compared. Patients were randomly allocated to the 4 week inpatient programme or to the 8 half day per week outpatient programme, or to a waiting list control group. Staff, teaching materials, and setting were the same for the two treatment groups. Patients were assessed pre-treatment, and at 1 month after discharge, and treated patients also at 6 months and 1 year after discharge, by assessors blind to treatment group; assessments included physical, functional and psychological measures, and medication use. In total, 121 mixed chronic pain patients (mean age 50 years; mean chronicity 8.1 years) were included in the study, following medical examination to ensure that no further medical treatment was appropriate. There was no change in the control group; inpatients and outpatients, comparable before treatment, both made significant improvements in physical performance and psychological function, and reduced medication use. Inpatients made greater gains, and maintained them better at 1 year; they also used less health care than outpatients. There were no outstanding predictors of improvement other than treatment group.
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Affiliation(s)
- C A C de Williams
- Inpatient Pain Management Unit, Guy's and St Thomas' Hospital Trust, St Thomas' Hospital,London, SE1 7EH,UK Division of Psychiatry and Psychology, United Medical and Dental Schools, St Thomas' Campus,London, SE1 7EH,UK Lewisham and Guy's Mental Health NHS Trust, Guy's Hospital,London SE1 9RT,UK Guy's and St Thomas' Hospital Trust, St Thomas' Hospital,London SE1 7EH,UK Trinity Hospice,London,UK Department of Medicine, United Medical and Dental Schools, St Thomas' Campus,London, SE1 7EH,UK Pain Management and Research Centre, Royal North Shore Hospital,Sr. Leonards, NSW 2065,Australia
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Wilson JJ, Gil KM. The efficacy of psychological and pharmacological interventions for the treatment of chronic disease-related and non-disease-related pain. Clin Psychol Rev 1996. [DOI: 10.1016/0272-7358(96)00029-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pain management has improved in the past few decades. Opioid analgesics have become the mainstay in the treatment of cancer pain whilst inter-disciplinary pain management programmes are the generally accepted approach to chronic pain of non-malignant origin. Recently some pain specialists have advocated the use of opioids in the long-term management of non-cancer pain. This has raised some fundamental questions about the purpose of pain management. Is it best to opt for maximum pain relief and comfort, or should one emphasise function and activity as higher priorities? Will the use of opioids create more autonomy for pain sufferers or will this add handicaps to lives which are already limited? Until more clinical outcome data are available we advocate caution in the use of opioid analgesia. Such caution can, and does, raise questions about the rights of the patient and the rights of the prescriber in a context where the facts do not point to a clear course of action.
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Affiliation(s)
- R G Large
- Department of Psychiatry and Behavioural Science, University of Auckland, New Zealand
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