Long-term opioid therapy: assessment of consequences and risks

Predicting first use of heroin from prescription opioid use subtypes: Insights from the Monitoring the Future longitudinal panel

BACKGROUND

Only a small proportion of individuals who initiate nonmedical use of prescription opioids (NUPO) transition to heroin, suggesting that more nuanced aspects of NUPO may be better indicators of risk for escalating opioid use trajectories. This study leveraged panel data to identify NUPO typologies based on NUPO characteristics associated with opioid risk trajectories (route of administration, motives) and compared rates of heroin initiation at follow-up across typologies.

METHODS

Latent class analyses were run among respondents with no history of heroin use from the Monitoring the Future Panel Study (base year N=10,408) at modal ages 18, 19/20, 21/22, 23/24, and 25/26. Indicators included oral NUPO, nonoral NUPO, and NUPO motives to experiment, have a good time with friends, get high, escape problems, manage pain, relax, and sleep. Heroin initiation at follow-ups through modal age 29/30 was predicted from class membership.

RESULTS

No NUPO, self-medication (oral, manage pain), recreational (oral, nonoral, experiment, get high, have a good time with friends), and mixed-motive (all routes, all motives) classes emerged. Heroin initiation rates did not differ across no NUPO and self-medication classes; recreational and mixed-motives classes initiated heroin at higher rates than the other classes and comparable rates to each other. Non-NUPO drug use prior to heroin initiation was prevalent in recreational and mixed-motive classes.

CONCLUSIONS

NUPO does not uniformly or uniquely increase risk for heroin initiation. Leveraging more nuanced indicators of risk for heroin use and targeting polysubstance use in addition to opioid-specific programming may enhance the efficacy of public health efforts.

Implementation and Preliminary Effectiveness of a Multidisciplinary Telemedicine Pilot Initiative for Patients with Chronic Non-Cancer Pain in Rural and Underserved Areas at a Major Academic Medical Center

Background

Arkansas lacks adequate access to high-quality pain care, as evidenced, in part, by it having the second highest opioid prescribing rate in the United States. To improve access to high-quality treatment of chronic pain, we developed the Arkansas Improving Multidisciplinary Pain Care and Treatment (AR-IMPACT) Telemedicine Clinic, a multidisciplinary and interprofessional team of specialists who provide evidence-based pain management for patients with chronic pain.

Methods

We conducted a single-arm pilot trial of the AR-IMPACT Telemedicine Clinic with rural, university-affiliated primary care clinics. We assessed the AR-IMPACT Telemedicine Clinic using an implementation framework and preliminary effectiveness measures. Specifically, we assessed 5 of the 8 implementation outcomes of the framework (ie, penetration, adoption, acceptability, appropriateness, and feasibility) using a mixed methods approach. To evaluate implementation outcomes, we used surveys, interviews, and administrative data. We used electronic health record data to measure preliminary effectiveness (ie, changes in average morphine milligram equivalents per day and pain and depression scores).

Results

The AR-IMPACT team saw 23 patients that were referred by 13 primary care physicians from three rural, university-affiliated primary care clinics over one year. Of the 19 patients willing to participate in the pilot study, 12 identified as women, 31.6% identified as Black, and over 50% had less than a bachelor's level education. Patients rated the clinic positively with high overall satisfaction. Referring physicians indicated high levels of appropriateness, acceptability, and feasibility of the program. AR-IMPACT team members identified several barriers and facilitators to the feasibility of implementing the program. No changes in preliminary effectiveness measures were statistically significant.

Conclusion

Overall, the AR-IMPACT Telemedicine Clinic obtained moderate penetration and adoption, was highly acceptable to patients, was highly acceptable and appropriate to providers, and was moderately feasible to providers and AR-IMPACT team members.

Use of Psychoactive Substances during the Perinatal Period: Guidelines for Interventions during the Perinatal Period from the French National College of Midwives

Based on their clinical practice and an extensive review of the literature, the authors propose a framework of procedures to be followed to provide services to all women of childbearing age who use psychoactive substances (alcohol, cannabis, cocaine, amphetamines, and opioids), especially during pregnancy or during the postpartum and breastfeeding periods, in view of their individual situations and environmental contexts.

Prescribed opioid use is associated with increased all-purpose emergency department visits and hospitalizations in community-dwelling older adults in the United States

BACKGROUND

The geriatric and health characteristics of older adults make them more susceptible to the effects of opioids than younger groups. The number of older adults in the United States visiting the emergency department (ED) and overusing opioids has increased in recent years. Research examining their relationship is, however, limited.

METHODS

Using information from the 2020 National Health Interview Survey (NHIS), we included older adults aged 65 and older. To investigate the relationship between prescribed opioid use and 12-months ED visits and hospitalizations, linear regression and logistic regression models were built while adjusting for age, sex, ethnicity, education, employment, general health status, history of depression, and living arrangement.

RESULTS

Our study population consisted of 8,631 participants (mean age 74.3). Most of them were females (58.3%) and Caucasian (81.6%). About 16% of the participants used prescribed opioids over the past 12 months. Of the participants with prescribed opioid use, 65.1% of them did so to treat chronic pain. The adjusted regression models revealed that prescribed opioid use was independently and positively associated with 12-months ED visits (β = 0.22, 95% confidence interval [CI] 0.18, 0.26) and hospitalizations (Odds ratio [OR] = 3.78, 95% CI 3.29, 4.35). Other risk factors for 12-months ED visits and/or hospitalizations included advanced age, male gender, unemployment/retirement, African American ethnicity, living alone, fair or poor general health status, and history of depression.

DISCUSSIONS

Clinicians should screen older adults at high risk for ED visits and hospitalizations and explore multimodal pain management with them to help them reduce/stop using opioids. These efforts may decrease their chronic pain, opioid use, opioid use-related adverse health outcomes, ED visits, as well as hospitalizations.

The iatrogenic opioid crisis: An example of 'institutional corruption of pharmaceuticals'?

RATIONALE

Prescribed opioids are major contributors to the international public health opioid crisis. Such widespread iatrogenic harms usually result from collective decision failures of healthcare organizations rather than solely of individual organizations or professionals. Findings from a system-wide safety analysis of the iatrogenic opioid crisis that includes roles of pertinent healthcare organizations may help avoid or mitigate similar future iatrogenic consequences. In this retrospective exploratory study, we report such an analysis.

METHODS

The study population encompassed the entire age spectrum and included those in whom opioids prescribed for chronic pain (unrelated to malignancy) were associated with death or morbidity. Root cause analysis, incorporating recent suggestions for improvement, was used to identify possible contributory factors from the literature. Based on their mandated roles and potential influences to prevent or mitigate the iatrogenic crisis, relevant organizations were grouped and stratified from most to least influential.

RESULTS

The analysis identified a chain of multiple interrelated causal factors within and between organizations. The most influential organizations were pharmaceutical, political, and drug regulatory; next: experts and their related societies, and publications. Less influential: accreditation, professional licensing and regulatory, academic and healthcare funding bodies. Collectively, their views and decisions influenced prescribing practices of frontline healthcare professionals and advocacy groups. Financial associations between pharmaceutical and most other organizations/groups were common. Ultimately, patients were adversely affected. There was a complex association with psychosocial variables.

LIMITATIONS

The analysis suggests associations not causality.

CONCLUSION

The iatrogenic crisis has multiple intricately linked roots. The major catalyst: pervasive pharma-linked financial conflicts of interest (CoIs) involving most other healthcare organizations. These extensive financial CoIs were likely triggers for a cascade of erroneous decisions and actions that adversely affected patients. The actions and decisions of pharma ranged from unethical to illegal. The iatrogenic opioid crisis may exemplify 'institutional corruption of pharmaceuticals'.

Deep Brain Stimulation of the Posterior Insula in Chronic Pain: A Theoretical Framework

INTRODUCTION

To date, clinical trials of deep brain stimulation (DBS) for refractory chronic pain have yielded unsatisfying results. Recent evidence suggests that the posterior insula may represent a promising DBS target for this indication.

METHODS

We present a narrative review highlighting the theoretical basis of posterior insula DBS in patients with chronic pain.

RESULTS

Neuroanatomical studies identified the posterior insula as an important cortical relay center for pain and interoception. Intracranial neuronal recordings showed that the earliest response to painful laser stimulation occurs in the posterior insula. The posterior insula is one of the only regions in the brain whose low-frequency electrical stimulation can elicit painful sensations. Most chronic pain syndromes, such as fibromyalgia, had abnormal functional connectivity of the posterior insula on functional imaging. Finally, preliminary results indicated that high-frequency electrical stimulation of the posterior insula can acutely increase pain thresholds.

CONCLUSION

In light of the converging evidence from neuroanatomical, brain lesion, neuroimaging, and intracranial recording and stimulation as well as non-invasive stimulation studies, it appears that the insula is a critical hub for central integration and processing of painful stimuli, whose high-frequency electrical stimulation has the potential to relieve patients from the sensory and affective burden of chronic pain.

An understanding of bone pain: A narrative review

Skeletal pathologies are often accompanied by bone pain, which has negative effects on the quality of life and functional status of patients. Bone pain can be caused by a wide variety of injuries and diseases including (poorly healed) fractures, bone cancer, osteoarthritis and also iatrogenic by skeletal interventions. Orthopedic interventions are considered to be the most painful surgical procedures overall. Two major groups of medication currently used to attenuate bone pain are NSAIDs and opioids. However, these systemic drugs frequently introduce adverse events, emphasizing the need for alternative therapies that are directed at the pathophysiological mechanisms underlying bone pain. The periosteum, cortical bone and bone marrow are mainly innervated by sensory A-delta fibers and C-fibers. These fibers are mostly present in the periosteum rendering this structure most sensitive to nociceptive stimuli. A-delta fibers and C-fibers can be activated upon mechanical distortion, acidic environment and increased intramedullary pressure. After activation, these fibers can be sensitized by inflammatory mediators, phosphorylation of acid-sensing ion channels and cytokine receptors, or by upregulation of transcription factors. This can result in a change of pain perception such that normally non-noxious stimuli are now perceived as noxious. Pathological conditions in the bone can produce neurotrophic factors that bind to receptors on A-delta fibers and C-fibers. These fibers then start to sprout and increase the innervation density of the bone, making it more sensitive to nociceptive stimuli. In addition, repetitive painful stimuli cause neurochemical and electrophysiological alterations in afferent sensory neurons in the spinal cord, which leads to central sensitization, and can contribute to chronic bone pain. Understanding the pathophysiological mechanisms underlying bone pain in different skeletal injuries and diseases is important for the development of alternative, targeted pain treatments. These pain mechanism-based alternatives have the potential to improve the quality of life of patients suffering from bone pain without introducing undesirable systemic effects.

Respiratory events associated with concomitant opioid and sedative use among Medicare beneficiaries with chronic obstructive pulmonary disease

BACKGROUND

Opioids and sedatives are commonly prescribed in chronic obstructive pulmonary disease (COPD) patients for symptoms of dyspnoea, pain, insomnia, depression and anxiety. Older adults are advised to avoid these medications due to increased adverse events, including respiratory events. This study examines respiratory event risks associated with concomitant opioid and sedative use compared with opioid use alone in older adults with COPD.

METHODS

A 5% nationally representative sample of Medicare beneficiaries with COPD and opioid use between 2009 and 2013 was used for this retrospective cohort study. Current and past concomitant use were identified using drug dispensed within 7 days from the censored date: at respiratory event, at death, or at 12 months post index. Concomitant opioid and sedative use were categorised into no overlap (opioid only), 1 to 10, 11 to 30, 31 to 60 and >60 days of total overlap. The primary outcome was hospitalisation or emergency department (ED) visits for respiratory events (COPD exacerbations or respiratory depression). Propensity score matching was implemented and semi-competing risk models were used to address competing risk by death.

RESULTS

Among 48 120 eligible beneficiaries, 1810 (16.7%) concomitant users were matched with 9050 (83.3%) opioid only users. Current concomitant use of 1 to 10, 11 to 30 and 31 to 60 days was associated with increased respiratory events (HRs (95% CI): 2.8 (1.2 to 7.3), 9.3 (4.9 to 18.2) and 5.7 (2.5 to 12.5), respectively), compared with opioid only use. Current concomitant use of >60 days or past concomitant use of ≤60 days was not significantly associated with respiratory events. Consistent findings were found in sensitivity analyses, including in subgroup analysis of non-benzodiazepine sedatives. Additionally, current concomitant use significantly increased risk of death.

CONCLUSION

Short-term and medium-term current concomitant opioid and sedative use significantly increased risk of respiratory events and death in older COPD Medicare beneficiaries. Long-term past concomitant users, however, demonstrated lower risks of these outcomes, possibly reflecting a healthy user effect or developed tolerance to the effects of these agents.

Psychiatry and the Opioid Overdose Crisis

For the third year in a row, the Centers for Disease Control and Prevention reported an unprecedented decline in life expectancy for the United States, a decline attributable mainly to drug overdose deaths and suicides. Drug overdoses have continued to rise and are now estimated to account for 70,237 deaths in 2017. The root causes of the modern opioid crisis are complex and traceable to at least 30 factors. A prime driver has been the health care system. Pressure on medical practitioners to resort to opioids for managing chronic pain led to a nation awash with prescription opioids. In 2017, an unprecedented action was taken by President Donald J. Trump as he signed an executive order establishing the President's Commission on Combating Drug Addiction and the Opioid Crisis, tasked with producing guidance on reversing the crisis. The 56 recommendations of the President's Commission report were grounded in advanced strategies for prevention, treatment, rescue, recovery support, research, improved data analytics, and accountability. With a focus on the quality of treatment services and recovery homes, the report calls for implementing high standards of care for treatment. Specialists in addiction medicine and addiction psychiatry are best positioned to develop and implement high-quality care.

Association between harm reduction strategies and healthcare utilization in patients on long-term prescribed opioid therapy presenting to acute healthcare settings: a protocol for a systematic review and meta-analysis

INTRODUCTION

Opioids are routinely used to treat a variety of chronic conditions associated with pain. However, they are a class of medications with a significant potential for adverse health effects, with and without misuse. Opioid misuse, as defined as inappropriate use of appropriately prescribed opioids, is becoming more well-recognized publicly but does not have clear treatment options. Opioid misuse has been linked to variety of poor outcomes and its consequences have a significant impact on healthcare resource utilization. The evidence on harm reduction strategies to mitigate adverse events prompting presentation to acute care settings for patients presenting with long-term opioid use is sparse.

METHODS AND ANALYSIS

We will perform a systematic review and meta-analysis to catalog effective harm reduction strategies and identify the most effective ones to reduce avoidable healthcare utilization in patients on long-term opioid therapy who present to acute health care settings with complications attributed to opioid misuse. A search strategy will be developed and executed by an information specialist; electronic databases (MEDLINE, EMBASE, CINAHL, Cochrane Library) and additional sources will be searched. Search themes will include opioids, chronic drug use, and acute healthcare settings. Citation screening, selection, quality assessment, and data abstraction will be performed in duplicate. A comprehensive inventory of harm reduction strategies will be developed. Data will be collected on patient-related outcomes associated with each identified harm reduction strategy. When sufficiently homogeneous data on interventions, population, and outcomes is available, it will be pooled for aggregate analysis. Evaluation of the methodological quality of individual studies and of the quality of the body of evidence will be performed. Our primary objective will be to identify harm reduction strategies that have been shown to result in clinically relevant and statistically significant improvements in patient outcomes and/or decreased healthcare utilization.

DISCUSSION

This study will better characterize harm reduction strategies for patients on long-term prescribed opioids presenting to acute healthcare settings. It will also add new knowledge and generate greater understanding of key knowledge gaps of the long-term prescribed opioid use and its impact on healthcare utilization.

SYSTEMATIC REVIEW REGISTRATION

CRD42018088962 .

Anti-nerve growth factor does not change physical activity in normal young or aging mice but does increase activity in mice with skeletal pain

Anti-nerve growth factor (anti-NGF) therapy has shown significant promise in attenuating several types of skeletal pain. However, whether anti-NGF therapy changes the level of physical activity in individuals with or without skeletal pain is largely unknown. Here, automated day/night activity boxes monitored the effects of anti-NGF treatment on physical activity in normal young (3 months old) and aging (18-23 months old) mice and mice with bone fracture pain. Although aging mice were clearly less active and showed loss of bone mass compared with young mice, anti-NGF treatment had no effect on any measure of day/night activity in either the young or aging mice. By contrast, in mice with femoral fracture pain, anti-NGF treatment produced a clear increase (10%-27%) in horizontal activity, vertical rearing, and velocity of travel compared with the Fracture + Vehicle group. These results suggest, just as in humans, mice titrate their level of physical activity to their level of skeletal pain. The level of skeletal pain may in part be determined by the level of free NGF that seems to rise after injury but not normal aging of the skeleton. In terms of bone healing, animals that received anti-NGF showed an increase in the size of calcified callus but no increase in the number of displaced fractures or time to cortical union. As physical activity is the best nondrug treatment for many patients with skeletal pain, anti-NGF may be useful in reducing pain and promoting activity in these patients.

New Insights in Understanding and Treating Bone Fracture Pain

PURPOSE OF REVIEW

This paper describes recent advances in understanding the mechanisms that drive fracture pain and how these findings are helping develop new therapies to treat fracture pain.

RECENT FINDINGS

Immediately following fracture, mechanosensitive nerve fibers that innervate bone are mechanically distorted. This results in these nerve fibers rapidly discharging and signaling the initial sharp fracture pain to the brain. Within minutes to hours, a host of neurotransmitters, cytokines, and nerve growth factor are released by cells at the fracture site. These factors stimulate, sensitize, and induce ectopic nerve sprouting of the sensory and sympathetic nerve fibers which drive the sharp pain upon movement and the dull aching pain at rest. If rapid and effective healing of the fracture occurs, these factors return to baseline and the pain subsides, but if not, these factors can drive chronic bone pain. New mechanism-based therapies have the potential to fundamentally change the way acute and chronic fracture pain is managed.

Treating Women Who Are Pregnant and Parenting for Opioid Use Disorder and the Concurrent Care of Their Infants and Children: Literature Review to Support National Guidance

OBJECTIVES

The prevalence of opioid use disorder (OUD) during pregnancy is increasing. Practical recommendations will help providers treat pregnant women with OUD and reduce potentially negative health consequences for mother, fetus, and child. This article summarizes the literature review conducted using the RAND/University of California, Los Angeles Appropriateness Method project completed by the US Department of Health and Human Services Substance Abuse and Mental Health Services Administration to obtain current evidence on treatment approaches for pregnant and parenting women with OUD and their infants and children.

METHODS

Three separate search methods were employed to identify peer-reviewed journal articles providing evidence on treatment methods for women with OUD who are pregnant or parenting, and for their children. Identified articles were reviewed for inclusion per study guidelines and relevant information was abstracted and summarized.

RESULTS

Of the 1697 articles identified, 75 were included in the literature review. The perinatal use of medication for addiction treatment (MAT, also known as medication-assisted treatment), either methadone or buprenorphine, within comprehensive treatment is the most accepted clinical practice, as withdrawal or detoxification risks relapse and treatment dropout. Medication increases may be needed with advancing pregnancy, and are not associated with more severe neonatal abstinence syndrome (NAS). Switching medication prenatally is usually not recommended as it can destabilize opioid abstinence. Postnatally, breastfeeding is seen as beneficial for the infant for women who are maintained on a stable dose of opioid agonist medication. Less is known about ideal pain management and postpartum dosing regimens. NAS appears generally less severe following prenatal exposure to buprenorphine versus methadone. Frontline NAS medication treatments include protocol-driven methadone and morphine dosing in the context of nonpharmacological supports.

CONCLUSIONS

Women with OUD can be treated with methadone or buprenorphine during pregnancy. NAS is an expected and manageable condition. Although research has substantially advanced, opportunities to guide future research to improve maternal and infant outcomes are provided.

Survey of Physician Perspective towards Management of Pain for Chronic Conditions in the Emergency Department

Sickle cell disease (SCD) pain is often acute-on-chronic, likening it to other chronic acute-on-chronic pain conditions. Pain treatment of SCD was already reported as inadequate prior to the current opioid epidemic, but attitudes underlying treatment were understudied. Understanding these attitudes prior to the current epidemic would be revealing. Therefore in 1997, before the current opioid epidemic, we surveyed physicians' attitudes toward pain management and treatment preferences for acute pain exacerbations in the Emergency Department in SCD versus those of chronic pancreatitis and chronic low back pain, two other acute-on-chronic pain diseases. Thirty-nine residency trainees were surveyed in a level one triage hospital. Resident estimates of the rate of opioid addiction in SCD were higher than estimates in both chronic pancreatitis and chronic low back pain. Most residents relied on their personal clinical experience rather than external sources of data or knowledge as the most important driver when they managed chronic pain. This survey research shows that, predating the current opioid epidemic, there was both a backdrop of opioid-phobia and a bias against treating SCD pain compared to other chronic pain conditions among our sample. Repeating this survey research among current training physicians, along with surveys of other attitudes, would provide useful comparisons.

Acceptance and Commitment Therapy to manage pain and opioid use after major surgery: Preliminary outcomes from the Toronto General Hospital Transitional Pain Service

Background: Chronic postsurgical pain (CPSP) and associated long-term opioid use are major public health concerns. Aims: The Toronto General Hospital Transitional Pain Service (TPS) is a multidisciplinary, hospital-integrated program developed to prevent and manage CPSP and support opioid tapering. This clinical practice-based study reports on preliminary outcomes of the TPS psychology program, which provides acceptance and commitment therapy (ACT) to patients at risk for CPSP and persistent opioid use. Methods: Ninety-one patients received ACT, whereas 252 patients did not (no ACT group). Patient outcomes were compared for the two groups at first and last TPS visits. Pain, pain interference, sensitivity to pain traumatization, pain catastrophizing, anxiety, depression, and opioid use were analyzed using two-way (Group [ACT, no ACT] × Time [first, last visit]) analyses of variance (ANOVAs). Results: Patients referred to ACT were more likely to report a mental health condition preoperatively (P < 0.001), had higher opioid use (P < 0.001) at the first postsurgical visit, and reported higher sensitivity to pain traumatization (P < 0.05) and anxiety (P < 0.05) than the no ACT group at both time points. Both groups showed reductions in pain, pain interference, pain catastrophizing, anxiety, and opioid use by the last TPS visit (P < 0.05). The ACT group demonstrated greater reductions in opioid use and pain interference and showed reductions in depressed mood (P = 0.001) by the end of treatment compared to the no ACT group. Conclusion: Preliminary outcomes suggest that ACT was effective in reducing opioid use while pain interference and mood improved.

A case report on the treatment of complex chronic pain and opioid dependence by a multidisciplinary transitional pain service using the ACT Matrix and buprenorphine/naloxone

In an era of growing concern about opioid prescribing, the postsurgical period remains a critical window with the risk of significant opioid dose escalation, particularly in patients with a history of chronic pain and presurgical opioid use. The purpose of this case report is to describe the multidisciplinary care of a complex, postsurgical pain patient by an innovative transitional pain service (TPS). A 59-year-old male with complex chronic pain, as well as escalating long-term opioid use, presented with a bleeding duodenal ulcer requiring emergency surgery. After surgery, the TPS provided integrated pharmacological and behavioral treatment, including buprenorphine combined with naloxone and acceptance and commitment therapy (ACT) using the ACT Matrix. The result was dramatic pain reduction and improved functioning and quality of life after 40+ years of chronic pain, thus changing the pain trajectory of a chronic, complex, opioid-dependent patient.

Orthopedic surgery and bone fracture pain are both significantly attenuated by sustained blockade of nerve growth factor

The number of patients suffering from postoperative pain due to orthopedic surgery and bone fracture is projected to dramatically increase because the human life span, weight, and involvement in high-activity sports continue to rise worldwide. Joint replacement or bone fracture frequently results in skeletal pain that needs to be adequately controlled for the patient to fully participate in needed physical rehabilitation. Currently, the 2 major therapies used to control skeletal pain are nonsteroidal anti-inflammatory drugs and opiates, both of which have significant unwanted side effects. To assess the efficacy of novel therapies, mouse models of orthopedic and fracture pain were developed and evaluated here. These models, orthopedic surgery pain and bone fracture pain, resulted in skeletal pain-related behaviors that lasted 3 weeks and 8 to 10 weeks, respectively. These skeletal pain behaviors included spontaneous and palpation-induced nocifensive behaviors, dynamic weight bearing, limb use, and voluntary mechanical loading of the injured hind limb. Administration of anti-nerve growth factor before orthopedic surgery or after bone fracture attenuated skeletal pain behaviors by 40% to 70% depending on the end point being assessed. These data suggest that nerve growth factor is involved in driving pain due to orthopedic surgery or bone fracture. These animal models may be useful in developing an understanding of the mechanisms that drive postoperative orthopedic and bone fracture pain and the development of novel therapies to treat these skeletal pains.

Opioids for chronic noncancer pain

Opioids are powerful medications with a history that includes use for pain relief and, at times, addiction. This history of therapy versus drug abuse continues to cloud their prescription today, despite reports of effective treatment for the chronic pain that certain diseases can bring. Here, Drs Antoin and Beasley review the use of opioid agents in medicine, highlight the importance of proper patient selection and education in their use, and convey how opioids can be a viable option today for successful therapy for chronic noncancer pain.

Nigella sativa extract affects conditioned place preference induced by morphine in rats

Objective:

Neuroprotective, antioxidant, anticonvulsant, and analgesic effects of Nigella sativa (NS) have been previously shown. The interaction of NS with opioid system has also been reported. In the present study, the effects of NS hydro-alcoholic extract on the acquisition and expression of morphine-induced conditioned place preference (CPP) in rats were evaluated.

Materials and Methods:

CPP was induced by injection of morphine (5 mg/kg, i.p.) on three consecutive days in compartment A of the CPP apparatus. Injection of NS extract (200 and 400 mg/kg, i.p.) 60 min before morphine administration on the conditioning days and 60 min before the post-conditioning phase was done for the evaluation of acquisition and expression effects, respectively. Conditioning effect of NS extract was also evaluated by injection of extract (200 or 400 mg/kg, i.p.) in the conditioning phase, instead of morphine in different groups. The difference in time which the animals spent in compartment A on the day before conditioning and the days after conditioning was determined and compared between groups.

Results:

The time spent by the rats in compartment A in the morphine group was greater than that in the saline group (P < 0.01). Both doses of NS extract decreased acquisition of morphine-induced CPP (P < 0.01 and P < 0.001), but had no significant effect on the expression of morphine CPP. Higher dose of the extract (400 mg) showed a significant conditioning effect which was comparable to the effect of morphine.

Conclusion:

The results of the present study showed that the hydro-alcoholic extract of NS has conditioning effect. It also decreased acquisition, but had no significant effect on the expression of morphine CPP.

Counselors' Experiences Treating Methadone-maintained Patients with Chronic Pain: A Needs Assessment Study

PURPOSE

: This study was designed to conduct a needs assessment concerning methadone counselors' experiences working with methadone-maintained patients with chronic pain and measure counselors' interest in receiving specialized training to treat such patients.

METHODS

: A survey, developed by the authors, was administered to 25 counselors with a combined caseload of 956 patients at 3 opioid agonist treatment programs.

RESULTS

: Patients with chronic pain comprised 27% of counselors' overall caseloads. Counselors believed that, on average, 46% of these patients' pain had a psychologic component and 56% exhibited continued drug use, which patients attributed to ongoing pain. Twenty-three counselors reported an interest in receiving specialized training in treating chronic pain. A variety of management issues, including monitoring the use of pain medications and providing pain management referrals, were reported.

CONCLUSIONS

: Findings from this needs assessment study suggest specific targets, which may be important to consider, in prospective specialized methadone maintenance treatment (MMT) counselor training and counseling for MMT patients with chronic pain.

Acquired pharmaco-dynamic opioid tolerance: a concept analysis

AIM

To report an analysis of the concept of acquired pharmaco-dynamic opioid tolerance.

BACKGROUND

Acquired pharmaco-dynamic opioid tolerance is a complex and poorly understood phenomenon associated with strong opioid therapy for managing pain. Critical review of the concept provides greater clarification of the attributes, assisting healthcare professionals in addressing pain and functional management of patients, particularly those with non-malignant pain.

DESIGN

Concept analysis.

DATA SOURCES

A systematic literature search was undertaken using electronic data bases: CINAHL, British Nursing Index, EMBase, Medline, Pubmed and AMED. All literature reviewed was in English and published between 1976 and 2012. The key search terms were 'chronic non-malignant pain', 'strong opioid therapy' and 'development of acquired pharmaco-dynamic opioid tolerance'; all possible variant terms were also searched.

METHOD

The Walker and Avant approach was used to guide the concept analysis.

RESULTS

The concept analysis revealed four empirical referents: plasticity, drug administration, reduced analgesic efficacy and increased drug dosing. Tachyphylexia was identified as a borderline case, opioid induced hyperalgesia as a related case and pseudo-tolerance as a contrary case. The antecedent is administration of an opioid analgesic drug and the consequences, increasing opioid drug dose to maintain analgesic effect.

CONCLUSION

Untangling the antecedents, empirical referents and consequences of tolerance help healthcare professionals understand its complexities. Improved knowledge may ultimately influence patient outcomes through the construction of better monitoring systems. This concept analysis may also provide insights for policy change and give empirical direction for future research.

Chronic pain and addiction: challenging co-occurring disorders

Chronic pain is commonly treated by prescribing an opioid medication. For those suffering from both chronic pain and substance dependence, barriers to adequate pain management increase. This often causes both disorders to exacerbate one another. Effective treatment may also be hampered by opioid-induced hyperalgesia, tolerance, physical dependence, "chemical coping," and diminished physical and emotional functioning. This article reviews current research trends, potential problems stemming from prescription opioid use, and suggestions for clinical practice.

Opioids in chronic noncancer pain: more faces from the crowd

BACKGROUND

The use of opioids for chronic noncancer pain (CNCP) remains very controversial. There are several randomized controlled trials, mostly in neuropathic pain, reporting efficacy and safety in the short term, but more long-term data are needed. Randomized controlled trials may be limited in providing data about the patients who benefit from often high-dose opioids over the long term. The present article provides details of these patients and adds to a previous case series.

METHODS

The present article contains 17 case reports of 11 CNCP conditions (followed to 2011) selected to illustrate specific issues from a survey of 84 patients with intractable CNCP treated with opioids and followed every three months for a median of 11 years. The previous published survey of this group reported outcomes of pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health-related quality of life (HRQL), immune status and sexual function. The outcome measures for that study included a numerical rating scale for pain, the Hospital Anxiety and Depression Scale, the Brief Pain Inventory Interference Scale, the Pain Disability Index and, for HRQL, the Short-Form Health Survey 12 version 2. Most patients in the total sample reported 50% or greater relief and a moderate improvement in disability. Scores for functional status and HRQL were not severely affected. Problematic use, tolerance and serious adverse effects, including constipation, were not major issues. These selected patient reports were chosen, not to illustrate optimal results, but rather important aspects of the diagnoses, opioids and doses, the paucity of intolerable adverse effects, particular issues (concurrent addiction history, bipolar disorder and combination therapy), disease-specific and other outcomes and duration of follow-up with complex pain problems.

RESULTS

Opioids were found to be safe and useful in the long term for these particular patients, as well as in the larger group from which they originated.

INTERPRETATION

These 17 reports of patients with intractable CNCP treated with opioids with some success over many years puts a face on more of the participants in the larger survey of 84 subjects, suggesting that this approach is effective and safe for some patients over many years.

Morphine administration and abrupt cessation alter the behavioral diurnal activity pattern

In mammals, there is an underlying mechanism that dictates the organism's biological functions and daily activity schedule, known as circadian rhythms, which play a major role in maintaining steady metabolism, homeostasis, and immunity. Limited research has been done investigating the effects of continuous opiate administration on the circadian rhythm activity pattern. A change in circadian activity pattern is suggested as an experimental model to demonstrate long-term effect of the drug. The objective of this study was to investigate the effects of morphine treatment on the long term activity (24 h) of the animal as well as the activity after abrupt removal, since prescribed medication containing morphine is widely used and abused and its long term effects are not known. Male Sprague-Dawley rats were contained in stable conditions with a standard light/dark cycle recordings taken before, during and after morphine pellet implantation. Cosinor analysis was used to fit a 24-hour curve to the activity pattern. Results indicate that morphine pellet administration alters the mesor, amplitude, the day-time and night-time activity levels, and demonstrates a remarkable change in the maximal circadian rhythm timing during the withdrawal period. The question whether morphine changes the circadian rhythm or a change in circadian rhythm results in tolerance and withdrawal is discussed.

Chronic non-cancer pain and the long-term efficacy and safety of opioids: Some blind men and an elephant?

Background

The use of opioids for chronic non-cancer pain (CNCP) remains very controversial. There are a number of randomized controlled trials (RCTs) showing efficacy and safety in the short-term, but long-term data are limited.

Methods

This article contains 10 case reports (followed to 2011) that were selected from a survey of 84 patients with intractable CNCP treated with opioids and followed every 3 months now for a median of 10 years. The previous published survey of this group reported outcomes of pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health-related quality of life (HRQL), immune status and sexual function. The outcome measures for that study included a numerical rating scale (NRS) for pain, Hospital Anxiety and Depression Scale (HADS), the Brief Pain Inventory Interference Scale (BPI-I), the Pain Disability Index (PDI), and for Health Related Quality of Life (HRQL) the Short Form Health Survey 12 version 2 (SF12v2). These selected patient reports were chosen to illustrate some important aspects of the diagnostic categories of CNCP, the opioids and doses used, particular issues (concurrent addiction history, bipolar disorder, and combination therapy), disease-specific and other outcomes (pain severity and relief, adverse effects, mood, function) and duration of follow-up with complex pain problems.

Results

Opioids were found to be safe and effective in the long-term for these particular patients, as well as in the larger group from which they originate. Most patients in the total sample reported 50% or greater relief and a moderate improvement in disability. Scores for functional status and HRQL were not severely affected (PDI and BPI-I ratings moderate or less and SF12v2 slightly below normative values for age). Problematic use, tolerance, and serious adverse effects including constipation were not major issues.

Conclusion

These 10 reports of patients with intractable CNCP treated with opioids with some success over many years put a face on some of the participants in the larger survey of 84 suggesting that this approach is effective and safe for some patients over many years.

Implications

These data may not be generalizable to a larger population of patients with CNCP because of the probable selection of patients who benefit and who do not have intolerable adverse effects.

The role of cyclo-oxygenase inhibitors in attenuating opioid-induced tolerance, hyperalgesia, and dependence

There is no denying that opioids are the most important analgesic drugs which are widely used in clinical situations. Still, prolonged administration of these drugs can cause to reduce their analgesic efficacy due to the development of tolerance. These drugs can also cause induction of hyperalgesia. In addition, long-term administration of opioids through reinforcing- and rewarding pathways of limbic system can result in expression of opioid dependence with the unintended consequences of opioid abuse/misuse and finally opioid addiction. As studies show, over-activity in cyclo-oxygenase pathways and production of prostaglandins due to long-term exposures of opioid have a critical role in the development of tolerance to antinociceptive effect of opioid, hyperalgesia, and opioid dependence. The present study aims at suggesting the hypothesis that through blending a non-steroid anti-inflammatory drug with opioid actively causes reduction in unwanted effects of opioid i.e. by inhibition of opioid-induced cyclo-oxygenase overactivity whereas it is well-known that the combination therapy via reducing opioid dosage reduces the unwanted effects.

[Do opioids induce hyperalgesia?]

Opioids are the most potent drugs for treatment of acute and chronic pain. However, accumulating evidence suggests that opioids may paradoxically also enhance pain, often referred to as opioid-induced hyperalgesia. Opioid-induced hyperalgesia is defined as an increased sensitivity to pain or a decreased pain threshold in response to opioid therapy. Several mechanisms have been proposed to support opioid-induced hyperalgesia. However, it remains unclear whether opioid-induced hyperalgesia develops during continuous chronic application of opioids or on their withdrawal. This review provides a comprehensive summary of clinical research concerning opioid-induced hyperalgesia and the molecular mechanisms of opioid withdrawal and opioid tolerance and other potential mechanisms which might induce hyperalgesia during opioid therapy will be discussed. The status quo of our knowledge will be summarized and the clinical relevance of opioid-induced hyperalgesia will be discussed.

The long-term safety and efficacy of opioids: a survey of 84 selected patients with intractable chronic noncancer pain

BACKGROUND

The use of opioids for chronic noncancer pain (CNCP) remains controversial. Despite a number of randomized controlled trials showing efficacy and safety in the short term, long-term data are limited.

OBJECTIVE

To survey a selected cohort of patients with intractable CNCP with regard to long-term efficacy and safety of opioids.

METHODS

The present study reports long-term results from a survey of 84 patients with CNCP. The majority of patients had neuropathic pain, were treated with opioids and were followed every three months for a median of 8.4 years. Outcomes examined were pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health-related quality of life, immune status, sexual function, morbidity and mortality. Measures included a numerical rating scale, the Hospital Anxiety and Depression Scale, Brief Pain Inventory interference scale, Pain Disability Index and Short-Form Health Survey 12, version 2.

RESULTS AND CONCLUSIONS

Both long- and short-acting opioids were reported to be effective, with few significant long-term adverse effects in many subjects in the present selected cohort. The majority of patients reported at least 50% or greater pain relief and a moderate improvement in disability. Functional status and health-related quality of life scores were not severely affected. Problematic opioid use, tolerance and serious adverse effects, including constipation, were not major issues. The authors emphasize that the results obtained in the present selected group may not be generalizable to all CNCP patients in whom opioids are being initiated.

Morphinofobia: the situation among the general population and health care professionals in North-Eastern Portugal

Background

Morphinofobia among the general population (GP) and among health care professionals (HP) is not without danger for the patients: it may lead to the inappropriate management of debilitating pain. The aim of our study was to explore among GP and HP the representation and attitudes concerning the use of morphine in health care.

Methods

A cross-sectional study was done among 412 HP (physicians and nurses) of the 4 hospitals and 10 community health centers of Beira Interior (Portugal)and among 193 persons of the GP randomly selected in public places. Opinions were collected through a translated self-administered questionnaire.

Results

A significant difference of opinion exists among GP and HP about the use of morphine. The word morphine first suggests drug to GP (36,2%) and analgesia to HP (32,9%.). The reasons for not using morphine most frequently cited are: for GP morphine use means advanced disease (56%), risk of addiction (50%), legal requirements (49,7%); for HP it means legal risks (56,3%) and adverse side effects of morphine such as somnolence - sedation (30,5%) The socio-demographic situation was correlated with the opinions about the use of morphine.

Conclusions

False beliefs about the use of morphine exist among the studied groups. There seems to be a need for developing information campaigns on pain management and the use of morphine targeting. Better training and more information of HP might also be needed.

Opioid pharmaceuticals and addiction: the issues, and research directions seeking solutions

There are few pharmaceuticals superior to opiates for the treatment of pain. However, with concerns of addiction, withdrawal and questionable efficacy for all types of pain, these compounds are far from a magical panacea for pain-relief. As it is unlikely that other classes of compounds will supersede the opioids in the very near future, it is important to both optimize current opioid therapies and curb the astounding diversion of opioids from their intended analgesic use to non-medical abuse. In optimizing opioid therapeutics it is necessary to enhance the clinical awareness of the benefits of treating pain and combine this with aggressive strategies to reduce diversion for non-medical use. At the heart of the issue of opioid misuse is the role of opioid systems in the reward circuitry, and the adaptive processes associated with repetitive opioid use that manifest during withdrawal. Emerging pharmacological insights of opioid receptors will be reviewed that provide future hope for developing opioid-based analgesics with reduced addictive properties and perhaps, reduced opponent processes. In addition, with the increased understanding of nociceptive circuitry and the molecules involved in transmitting pain, new therapeutic targets have become evident that may result in effective analgesics either alone or in combination with current opioid therapies.

Shared mechanisms for opioid tolerance and a transition to chronic pain

Clinical pain conditions may remain responsive to opiate analgesics for extended periods, but such persistent acute pain can undergo a transition to an opiate-resistant chronic pain state that becomes a much more serious clinical problem. To test the hypothesis that cellular mechanisms of chronic pain in the primary afferent also contribute to the development of opiate resistance, we used a recently developed model of the transition of from acute to chronic pain, hyperalgesic priming. Repeated intradermal administration of the potent and highly selective mu-opioid agonist, [d-Ala(2),N-MePhe(4),gly-ol]-enkephalin (DAMGO), to produce tolerance for its inhibition of prostaglandin E(2) hyperalgesia, simultaneously produced hyperalgesic priming. Conversely, injection of an inflammogen, carrageenan, used to produce priming produced DAMGO tolerance. Both effects were prevented by inhibition of protein kinase Cepsilon (PKCepsilon). Carrageenan also induced opioid dependence, manifest as mu-opioid receptor antagonist (d-Phe-Cys-Tyr-d-Trp-Orn-Thr-Pen-Thr-NH(2))-induced hyperalgesia that, like priming, was PKCepsilon and G(i) dependent. These findings suggest that the transition from acute to chronic pain, and development of mu-opioid receptor tolerance and dependence may be linked by common cellular mechanisms in the primary afferent.

Trends in long-term opioid therapy for chronic non-cancer pain

OBJECTIVE

To report trends and characteristics of long-term opioid use for non-cancer pain.

METHODS

CONSORT (CONsortium to Study Opioid Risks and Trends) includes adult enrollees of two health plans serving over 1 per cent of the US population. Using automated data, we constructed episodes of opioid use between 1997 and 2005. We estimated age-sex standardized rates of opioid use episodes beginning in each year (incident) and on-going in each year (prevalent), and the per cent change in rates annualized (PCA) over the 9-year period. Long-term episodes were defined as > 90 days with 120+ days supply or 10+ opioid prescriptions in a given year.

RESULTS

Over the study period, incident long-term use increased from 8.5 to 12.1 per 1000 at Group Health (GH) (6.0% PCA), and 6.3 to 8.6 per 1000 at Kaiser Permanente of Northern California (KPNC) (5.5% PCA). Prevalent long-term use doubled from 23.9 to 46.8 per 1000 at GH (8.5% PCA), and 21.5 to 39.2 per 1000 at KPNC (8.1% PCA). Non-Schedule II opioids were the most commonly used opioid among patients engaged in long-term opioid therapy, particularly at KPNC. Long-term use of Schedule II opioids also increased substantially at both health plans. Among prevalent long-term users in 2005, 28.6% at GH and 30.2% at KPNC were also regular users of sedative hypnotics.

CONCLUSION

Long-term opioid therapy for non-cancer pain is increasingly prevalent, but the benefits and risks associated with such therapy are inadequately understood. Concurrent use of opioids and sedative-hypnotics was unexpectedly common and deserves further study.

The interface between substance abuse and chronic pain management in primary care: a curriculum for medical residents

OBJECTIVES

To develop and assess a housestaff curriculum on opioid and other substance abuse among patients with chronic noncancer pain (CNCP).

METHODS

The two-hour, case-based curriculum delivered to small groups of medical housestaff sought to improve assessment and management of opioid-treated CNCP patients, including those with a substance use disorder. A two-page pre-post survey was administered to assess self-efficacy change on a scale from 1 (strongly disagree) to 5 (strongly agree).

RESULTS

Of 47/50 (94%) respondents, self-efficacy significantly improved across all items (mean pre vs. post ratings, P <.001). Housestaff were more prepared to manage patients on chronic opioid medication (2.8 vs. 3.8), including those with substance use disorders (2.3 vs. 3.4). They felt more prepared to identify opioid dependence (2.8 vs. 3.9) and overall rated the curriculum favorably (4.2).

CONCLUSIONS

The brief curriculum was well received and appears effective. Further study is needed to determine practice impact.

The role of tramadol ER in the treatment of chronic pain

Despite its high prevalence, chronic pain is suboptimally treated in approximately one half of affected patients. Failure to recognise and manage comorbid physical and psychosocial impairments may contribute to the perpetuation of chronic pain. Knowledge of the potential advantages and disadvantages of available analgesic medications will permit informed selection of the appropriate medication for the individual chronic pain patient. Ultimate therapeutic goals will also influence analgesic medication selection. For the patient with chronic pain requiring analgesic treatment for an extended period of time, long-acting analgesics are recommended. Theoretically, these agents will provide sustained analgesia by minimising the end-of-dose pain that is often seen with short-acting medications, with improved patient convenience and a potential for reduced risk of adverse events. The extended-release formulation of tramadol (tramadol ER) has proven efficacy in chronic pain conditions such as osteoarthritis and low back pain, as well as a favourable tolerability profile. In addition, tramadol ER has been shown in clinical trials to improve pain-related sleep disturbances and physical function in patients with chronic pain from osteoarthritis and low back pain.

Treadmill exercise reduces self-administration of morphine in male rats

Exercise can activate the same pathways as morphine. The aim of the present study was to clarify the effect of short-term and mid-term exercises on the self-administration of morphine in rats. Male Wistar rats were initially trained to receive small pellets of food by pressing the active lever in self-administration apparatus. Rats were divided into 4 groups: Saline, Morphine, Exercise 1 (11 days) and Exercise 2 (30 days). Their jugular vein was cannulated. The animals were placed in self-administration apparatus and allowed to self-administer morphine (0.5mg per infusion all test groups) or saline (Saline group) during consecutive days, for 2h/sessions. In the group 1 the rats were running before each session of self-administration and of group Exercise 2, 30 days before surgery as well as before each session. The pressing numbers of active and passive levers in each group and among different groups were compared. The number of active lever pressing of Morphine group was significantly higher than Saline group (p<0.001). In Exercise 1 and Exercise 2 groups, the number of active lever pressing was significantly lower than Morphine group (p<0.001). As exercise can activate many neurotransmitter systems involved in the addiction process and increase the release of endorphins, it is likely that could decrease the morphine self-administration in this experimental setup.

Pain and addiction: managing risk through comprehensive care

The use of controlled substances, including opioids, in people who may suffer from concurrent substance use disorders presents challenges to the healthcare professional. Pain and addiction can coexist either as a continuum or separate comorbid conditions. Success in the treatment of either condition requires an approach that encompasses the biopsychosocial needs of the patient. In pain management, controlled substances can be either the problem or the solution, depending on the healthcare professional's training and perspective. Not all patients on opioid pharmacotherapy do well. Some, with inadequate treatment responses, may actually improve on discontinuation of their opioids. Therefore, in any trial of pharmacotherapy, there must be a clear exit strategy as part of the treatment plan. The goal of this article is to explore the importance of making reasoned clinical decisions when faced with aberrant behavior, which is when the patient steps outside the boundaries of the agreed on treatment plan and is established as early as possible in the doctor-patient relationship. In this case, it is essential to separate the "motive" from the "problematic behavior" when trying to interpret the implications of aberrant behavior rather than simply applying a diagnostic label of addiction, which may or may not be correct.

Reported lifetime aberrant drug-taking behaviors are predictive of current substance use and mental health problems in primary care patients

BACKGROUND

The aim of this report is to determine the frequency of aberrant drug behaviors and their relationship to substance abuse disorders in a large primary sample of patients receiving opioids for chronic pain.

METHODS

The data utilized for this report was obtained from 904 chronic pain patients receiving opioid therapy from their primary care physician. A questionnaire was developed based on 12 aberrant drug behaviors reported in the clinical literature. The diagnosis of a current substance use disorder was determined using Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition(DSM-IV) criteria.

RESULTS

The average duration of chronic pain in the sample was 16 years and for opioid therapy, 6.4 years. Of the patients, 80.5% reported one or more lifetime aberrant drug behaviors. The most frequent behaviors reported included early refills (41.7%), increase dose without physician consent (35.7%), and felt intoxicated from opioids (32.2%). Only 1.1% of subjects with 1-3 aberrant behaviors (N = 464, 51.2%) met DSM-IV criteria for current opioid dependence compared with 9.9% of patients with four or more behaviors (N = 264, 29.3%). Persons with positive urine toxicology tests for cocaine were 14 times more likely to report four or more behaviors than no behaviors (14.1% vs 1.1%). A logistic model found that subjects who reported four or more aberrant behaviors were more likely to have a current substance use disorder (odds ratio [OR] 10.14; 3.72, 27.64), a positive test for cocaine (odds ratio [OR] 3.01; 1.74, 15.4), an Addiction Severity Index (ASI) psychiatric composite score >0.5 (OR 2.38; 1.65, 3.44), male gender (OR 2.08: 1.48, 2.92), and older age (OR 0.69; 0.59, 0.81) compared with subjects with three or fewer behaviors. Pain levels, employment status, and morphine equivalent dose do not enter the model.

CONCLUSIONS

Patients who report four or more aberrant drug behaviors are associated with a current substance use disorder and illicit drug use, whereas subjects with up to three aberrant behaviors have a very low probability of a current substance abuse disorder. Four behaviors--oversedated oneself, felt intoxicated, early refills, increase dose on own--appear useful as screening questions to predict patients at greatest risk for a current substance use disorders.