Opioids in Chronic Pain Management

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Opioids in Chronic Pain Management

• Benefits and Risks
• Side effects constipation, sleep disruption,
  altered mental status, itching, nausea,
  respiratory depression
• Addiction vs. Dependence
• Assessing whether medication improves quality of
  life and participation in life or diminishes
  them

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Benefits of Opioids for Pain

• Opioids take the edge off pain or make it
  easier to manage it
• Opioids do not eliminate pain, in therapeutic
  doses

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Goals of Opioid Use

• In Cancer Pain Improved Quality of Life
• Relief of suffering, even if there is sedation,
  etc.
• In Nonmalignant Pain Improved Function

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Timing

• Short-acting/Rescue medications codeine,
  hydrocodone, oxycodone, morphine
• Drug level
• time

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Problems with Short-acting Medications

• Drug level Loaded
• In pain
• Time

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Long-acting narcotics

• Drug level
• Time
• Fentanyl patches (Duragesic)
• Methadone
• MS Contin
• OxyContin
• Need to be dosed on a schedule, not prn

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Side Effects of Opioids

• Nausea and Vomiting
• Constipation
• Sedation- sleepiness
• Respiratory depression
• Urinary retention (difficulty peeing)
• Dysphoria depression
• Gonadal atrophy
• Myoclonus, muscular rigidity
• Increase in Pain Sensitivity

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Opioid-induced Hyperalgesia

• Animal studies show that repeated opioid
  administration. . . can lead to a progressive and
  lasting reduction of baseline nociceptive
  thresholds, resulting in an increase in pain
  sensitivity.
• The decreased baseline nociceptive thresholds
  lasted as long as 5 days after the cessation of
  four fentanyl bolus injections

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Opioid-induced Hyperalgesia

• Six chronic low back pain patients were assessed
  for both opioid tolerance and opioid-induced
  hyperalgesia using quantitative sensory testing
  (cold and heat) before and after the institution
  of oral morphine therapy.
• Preliminary results showed hyperalgesia and
  tolerance with cold but no hyperalgesia with heat
  or analgesic tolerance to heat pain.
• Chu L.F., Clark D.J., Angst M.S.  Opioid
  tolerance and hyperalgesia in chronic pain
  patients after one month of oral morphine
  therapy a preliminary prospective study.  J
  Pain 7. (1) 43-48.2006

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Opioid-induced Hyperalgesia

• Patients treated intraoperatively with
  remifentanil reported more postoperative pain
  than the matched nonopioid controls
• Vinik H.R., Igor K.  Rapid development of
  tolerance to analgesia during remifentanil
  infusion in humans.  Anesth Analg 86. 307-311.1998
   Crawford M.W., Hickey C., Zaarour C., et al 
  Development of acute opioid tolerance during
  infusion of remifentanil for pediatric scoliosis
  surgery.  Anesth Analg 102. (6) 1662-1667.2006 
  
• Guignard B., Bossard A.E., Coste C., et al 
  Acute opioid tolerance intraoperative
  remifentanil increases postoperative pain and
  morphine requiremnt.  Anesthesiology 93. (2)
  409-417.2000 

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Opioid-induced Hyperalgesia

• A number of case reports document decreases in
  pain with stopping opioids
• Wilson G.R., Reisfield G.M.  Morphine
  hyperalgesia a case report.  Am J Hosp Palliat
  Care 20. (6) 459-461.2003 Mercadante
  S., Ferrera P., Villari P., et al  Hyperalgesia
  an emerging iatrogenic syndrome.  J Pain Symptom
  Manage 26. (2) 769-775.2003 
• Heger S., Maier C., Otter K., et al  Morphine
  induced allodynia in a child with brain tumour.
   BMJ 319. (7210) 627-629.1999 
• Sjogren P., Jensen N.H., Jensen T.S. 
  Disappearance of morphine-induced hyperalgesia
  after discontinuing or substituting morphine with
  opioid agonists.  Pain 59. 313-316.1994
• Mechanism may be NMDA receptor-mediated central
  sensitization
•  

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Some Definitions

• Tolerance is a state resulting from regular use
  of opioid(s) in which an increased dose of the
  substance is needed to produce the desired
  effect.
• Physical dependence is a physiologic state of
  adaptation to a specific opioid(s) characterized
  by the emergence of a withdrawal syndrome during
  abstinence, which may be relieved in total or in
  part by re-administration of the substance.

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Definitions

• Withdrawal syndrome is a specific constellation
  of signs and symptoms due to the abrupt cessation
  of, or reduction in, a regularly administered
  dose of opioid(s).
• Pseudoaddiction Medication-seeking behaviors
  that arise as a result of pain being poorly
  controlled

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Definitions

• Addiction is a disease process involving use of
  opioid(s) wherein there is a loss of control,
  compulsive use, and continued use despite adverse
  social, physical, psychological, occupational, or
  economic consequences.
• Substance abuse is the use of any substance(s)
  for non-therapeutic purposes or use of
  medication for purposes other than those for
  which it is prescribed.

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Patients vs. Addicts

• Control of medication
• Medications increase quality of life
• Medications are decreased if side effects occur
• Concerned about medical problem
• Follow the contract
• Medications left over

• Med use not controlled
• Medications decrease quality of life
• Medications continued in the face of side effects
• Lack of concern about medical problems
• Ignore the contract
• Never have medication left often have stories
  about drug losses and shortages

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Addiction in Patients with Chronic Pain

• (1)  Intense desire for the drug and overwhelming
  concern about its continued availability
  (psychological dependence)
• (2)  Evidence of compulsive drug use
• unsanctioned dose escalation
• continued dosing despite significant side effects
• Use of drug to treat symptoms not targeted by
  therapy
• Unapproved use during period of no symptoms
• Or see next slide

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Addiction in Patients with Chronic Pain

• (3) Evidence of one or more of a group of
  associated behaviors
• manipulation of the treating physician or
  medical system for the purposes of obtaining
  additional drug (altering prescriptions, for
  example)
• Acquisition of drugs from other medical sources
  or from a nonmedical source
• Drug hoarding or sales
• Unapproved use of other drugs (particularly
  alcohol or other sedatives/hypnotics) during
  opioid therapy

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Questions to Ask

• Is the persons day centered around taking
  medication?
• Does the person take pain medication only on
  occasion, perhaps three or four pills per week?
• Have there been any other chemical (alcohol or
  drug) abuse problems in the persons life?
• Does the person in pain spend most of the day
  resting, avoiding activity, or feeling depressed?
  
• Is the pain person able to function (work,
  household chores, and play) with pain medication
  in a way that is clearly better than without?

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Signs Someone Is Being Harmed More Than Helped by
Pain Medication

• Sleeping too much or having days and nights
  confused
• Decrease in appetite
• Inability to concentrate or short attention span
• Mood swings (especially irritability)
• Lack of involvement with others
• Difficulty functioning due to drug effects
• Use of drugs to regress rather than to facilitate
  involvement in life
• Lack of attention to appearance and hygiene

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Addiction Issues with Non-Opioids

• Many of the same questions apply when looking at
  use of
• Muscle Relaxants
• Cannabis
• Other adjunctive medications
• Anticonvulsants
• Etc.

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Adjunctive Medications

• Topical lidocaine, capsaicin,
  antiinflammatories, other
• Antidepressants
• Anticonvulsants
• Antiarrhythmic drugs
• Ultram

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Antidepressants for Pain

• Work by affecting neurotransmitters
• Do not only work for treating pain by improving
  depression.
• Work as well in non-depressed people as in people
  with depression
• Effectiveness for pain does not correlate with
  effectiveness for depression
• Do not work for all types of pain.

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Stopping or Tapering Opioids

• Withdrawal Symptoms
• Anxiety/Restlessness
• Sweating
• Insomnia
• Diarrhea
• Nausea, vomiting
• Yawning, rhinorrhea (runny nose)
• Transient increase in pain

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Treatment of Withdrawal

• Each of the symptoms of withdrawal can be
  treated, and herbal support is also available for
  opioid withdrawal
• Passionflower
• Clonidine
• Lomotil
• Hydroxyzine
• Trazodone
• Etc.