Skip to main content

Advertisement

SpringerLink
Log in

Medication Overuse in Chronic Pain

  • Other Pain (N Vadivelu and A Kaye, Section Editors)
  • Published:
Current Pain and Headache Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

Chronic pain is usually managed by various pharmacotherapies after exhausting the conservative modalities such as over-the-counter choices. The goal of this review is to investigate current state of opioids and non-opioid medication overuse that includes NSAIDs, skeletal muscle relaxants, antidepressants, membrane stabilization agents, and benzodiazepine. How to minimize medication overuse and achieve better outcome in chronic pain management?

Recent Findings

Although antidepressants and membrane stabilization agents contribute to the crucial components for neuromodulation, opioids were frequently designated as a rescue remedy in chronic pain since adjunct analgesics usually do not provide instantaneous relief. The updated CDC guideline for prescribing opioids has gained widespread attention via media exposure. Both patients and prescribers are alerted to respond to the opioid epidemic and numerous complications. However, there has been overuse of non-opioid adjunct analgesics that caused significant adverse effects in addition to concurrent opioid consumption. It is a common practice to extrapolate the WHO three-step analgesic ladder for cancer pain to apply in non-cancer pain that emphasizes solely on pharmacologic therapy which may result in overuse and escalation of opioids in non-cancer pain. There has been promising progress in non-pharmacologic therapies such as biofeedback, complementary, and alternative medicine to facilitate pain control instead of dependency on pharmacologic therapies.

Summary

This review article presents the current state of medication overuse in chronic pain and proposes precaution to balance the risk and benefit ratio. It may serve as a premier for future study on clinical pathway for comprehensive chronic pain management and reduce medication overuse.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Manchikanti L, Cash KA, Malla Y, Pampati V, Fellows B. A prospective evaluation of psychotherapeutic and illicit drug use in patients presenting with chronic pain at the time of initial evaluation. Pain Physician. 2013;16(1):E1–E13.

    PubMed  Google Scholar 

  2. Cheatle MD. Prescription opioid misuse, abuse, morbidity, and mortality: balancing effective pain management and safety. Pain Med. 2015;16 Suppl 1:S3–8.

    Article  PubMed  Google Scholar 

  3. Timmerman L, Stronks DL, Groeneweg JG, Huygen FJ. Prevalence and determinants of medication non-adherence in chronic pain patients: a systematic review. Acta Anaesthesiol Scand. 2016;60(4):416–31.

    Article  CAS  PubMed  Google Scholar 

  4. Thielke S, Shortreed SM, Saunders K, Turner JA, LeResche L, von Korff M. A prospective study of predictors of long-term opioid use among patients with chronic non-cancer pain. Clin J Pain. 2016.

  5. Sun EC, Darnall B, Baker LC, Mackey S. Incidence of and risk factors for chronic opioid use among opioid-naive patients in the postoperative period. JAMA Intern Med. 2016.

  6. Gudin JA, Mogali S, Jones JD, Comer SD. Risks, management, and monitoring of combination opioid, benzodiazepines, and/or alcohol use. Postgrad Med. 2013;125(4):115–30.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Whittle SL, Richards BL, Husni E, Buchbinder R. Opioid therapy for treating rheumatoid arthritis pain. Cochrane Database Syst Rev. 2011;11:CD003113.

    Google Scholar 

  8. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, et al. 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(4):276–86.

    Article  PubMed  Google Scholar 

  9. Berthelot JM, Darrieutort-Lafitte C, Le Goff B, Maugars Y. Strong opioids for noncancer pain due to musculoskeletal diseases: not more effective than acetaminophen or NSAIDs. Joint Bone Spine. 2015;82(6):397–401.

    Article  CAS  PubMed  Google Scholar 

  10. • Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, tolerability, and dose-dependent effects of opioid analgesics for low back pain: a systematic review and meta-analysis. JAMA Intern Med. 2016;176(7):958–68. It is a refreshing review that prompts clinicians to update on prescription of opioid for back pain.

    Article  PubMed  Google Scholar 

  11. Bandieri E, Romero M, Ripamonti CI, Artioli F, Sichetti D, Fanizza C, et al. Randomized trial of low-dose morphine versus weak opioids in moderate cancer pain. J Clin Oncol. 2016;34(5):436–42.

    Article  CAS  PubMed  Google Scholar 

  12. Jerome J, Topham R, Dematatis A, Corteville J. Treatment outcomes after combination interventional and cognitive motivational counseling on analgesic medication use in patients with chronic spine pain. Pain Physician. 2015;18(3):287–97.

    PubMed  Google Scholar 

  13. Trang T, Al-Hasani R, Salvemini D, Salter MW, Gutstein H, Cahill CM. Pain and poppies: the good, the bad, and the ugly of opioid analgesics. J Neurosci. 2015;35(41):13879–88.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. •• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA. 2016;315(15):1624–45. It is a vital article to endorse benefits and risks of opioids, improve safety and effectiveness, and reduce risks associated with long-term opioid therapy.

    Article  CAS  PubMed  Google Scholar 

  15. Pappagallo M, Sokolowska M. The implications of tamper-resistant formulations for opioid rotation. Postgrad Med. 2012;124(5):101–9.

    Article  PubMed  Google Scholar 

  16. Cicero TJ, Ellis MS. Abuse-deterrent formulations and the prescription opioid abuse epidemic in the United States: lessons learned from OxyContin. JAMA Psychiat. 2015;72(5):424–30.

    Article  Google Scholar 

  17. Arout CA, Edens E, Petrakis IL, Sofuoglu M. Targeting opioid-induced hyperalgesia in clinical treatment: neurobiological considerations. CNS Drugs. 2015;29(6):465–86.

    Article  CAS  PubMed  Google Scholar 

  18. Chen L, Sein M, Vo T, Amhmed S, Zhang Y, Hilaire KS, et al. Clinical interpretation of opioid tolerance versus opioid-induced hyperalgesia. J Opioid Manag. 2014;10(6):383–93.

    Article  PubMed  Google Scholar 

  19. Eisenberg E, Suzan E, Pud D. Opioid-induced hyperalgesia (OIH): a real clinical problem or just an experimental phenomenon? J Pain Symptom Manag. 2015;49(3):632–6.

    Article  Google Scholar 

  20. Katz NP, Paillard FC, Edwards RR. Review of the performance of quantitative sensory testing methods to detect hyperalgesia in chronic pain patients on long-term opioids. Anesthesiology. 2015;122(3):677–85.

    Article  CAS  PubMed  Google Scholar 

  21. Giamberardino MA, Mitsikostas DD, Martelletti P. Update on medication-overuse headache and its treatment. Curr Treat Options Neurol. 2015;17(8):368.

    Article  PubMed  Google Scholar 

  22. Ansari H, Kouti L. Drug interaction and serotonin toxicity with opioid use: another reason to avoid opioids in headache and migraine treatment. Curr Pain Headache Rep. 2016;20(8):50.

    Article  PubMed  Google Scholar 

  23. Cheatle MD, Webster LR. Opioid therapy and sleep disorders: risks and mitigation strategies. Pain Med. 2015;16 Suppl 1:S22–6.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Van Ryswyk E, Antic N. Opioids and sleep disordered breathing. Chest. 2016.

  25. Correa D, Farney RJ, Chung F, Prasad A, Lam D, Wong J. Chronic opioid use and central sleep apnea: a review of the prevalence, mechanisms, and perioperative considerations. Anesth Analg. 2015;120(6):1273–85.

    Article  CAS  PubMed  Google Scholar 

  26. Larochelle MR, Zhang F, Ross-Degnan D, Wharam JF. Trends in opioid prescribing and co-prescribing of sedative hypnotics for acute and chronic musculoskeletal pain: 2001-2010. Pharmacoepidemiol Drug Saf. 2015;24(8):885–92.

    Article  PubMed  Google Scholar 

  27. Hawkins EJ, Malte CA, Hagedorn HJ, Berger D, Frank A, Lott A, et al. Survey of primary care and mental health prescribers’ perspectives on reducing opioid and benzodiazepine co-prescribing among veterans. Pain Med. 2016.

  28. Hawkins EJ, Malte CA, Grossbard JR, Saxon AJ. Prevalence and trends of concurrent opioid analgesic and benzodiazepine use among veterans affairs patients with post-traumatic stress disorder, 2003-2011. Pain Med. 2015;16(10):1943–54.

    Article  PubMed  Google Scholar 

  29. Nielsen S, Lintzeris N, Bruno R, Campbell G, Larance B, Hall W, et al. Benzodiazepine use among chronic pain patients prescribed opioids: associations with pain, physical and mental health, and health service utilization. Pain Med. 2015;16(2):356–66.

    Article  PubMed  Google Scholar 

  30. Park TW, Saitz R, Nelson KP, Xuan Z, Liebschutz JM, Lasser KE. The association between benzodiazepine prescription and aberrant drug-related behaviors in primary care patients receiving opioids for chronic pain. Subst Abus. 2016.

  31. Giummarra MJ, Gibson SJ, Allen AR, Pichler AS, Arnold CA. Polypharmacy and chronic pain: harm exposure is not all about the opioids. Pain Med. 2015;16(3):472–9.

    Article  PubMed  Google Scholar 

  32. Gauntlett-Gilbert J, Gavriloff D, Brook P. Benzodiazepines may be worse than opioids: negative medication effects in severe chronic pain. Clin J Pain. 2016;32(4):285–91.

    Article  PubMed  Google Scholar 

  33. Cavagna L, Caporali R, Trifiro G, Arcoraci V, Rossi S, Montecucco C. Overuse of prescription and OTC non-steroidal anti-inflammatory drugs in patients with rheumatoid arthritis and osteoarthritis. Int J Immunopathol Pharmacol. 2013;26(1):279–81.

    Article  CAS  PubMed  Google Scholar 

  34. Enthoven WT, Roelofs PD, Deyo RA, van Tulder MW, Koes BW. Non-steroidal anti-inflammatory drugs for chronic low back pain. Cochrane Database Syst Rev. 2016;2:CD012087.

    PubMed  Google Scholar 

  35. Kroon FP, van der Burg LR, Ramiro S, Landewé RB, Buchbinder R, Falzon L, et al. Non-steroidal anti-inflammatory drugs (NSAIDs) for axial spondyloarthritis (ankylosing spondylitis and non-radiographic axial spondyloarthritis). Cochrane Database Syst Rev. 2015;7:CD010952.

    Google Scholar 

  36. Wong JJ, Côté P, Ameis A, Varatharajan S, Varatharajan T, Shearer HM, et al. Are non-steroidal anti-inflammatory drugs effective for the management of neck pain and associated disorders, whiplash-associated disorders, or non-specific low back pain? A systematic review of systematic reviews by the Ontario Protocol for Traffic Injury Management (OPTIMa) Collaboration. Eur Spine J. 2016;25(1):34–61.

    Article  PubMed  Google Scholar 

  37. • Pergolizzi Jr JV, Raffa RB, Nalamachu S, Taylor Jr R. Evolution to low-dose NSAID therapy. Pain Manag. 2016;6(2):175–89. It is a revolutionary concept to challenge the traditional concept of titration up NSAID use to achieve maximal benefit.

    Article  PubMed  Google Scholar 

  38. Richards BL, Whittle SL, Buchbinder R. Antidepressants for pain management in rheumatoid arthritis. Cochrane Database Syst Rev. 2011;11:CD008920.

    Google Scholar 

  39. Reeves RR, Burke RS, Kose S. Carisoprodol: update on abuse potential and legal status. South Med J. 2012;105(11):619–23.

    Article  PubMed  Google Scholar 

  40. Toth PP, Urtis J. Commonly used muscle relaxant therapies for acute low back pain: a review of carisoprodol, cyclobenzaprine hydrochloride, and metaxalone. Clin Ther. 2004;26(9):1355–67.

    Article  CAS  PubMed  Google Scholar 

  41. Schukro RP, Oehmke MJ, Geroldinger A, Heinze G, Kress HG, Pramhas S. Efficacy of duloxetine in chronic low back pain with a neuropathic component: a randomized, double-blind, placebo-controlled crossover trial. Anesthesiology. 2016;124(1):150–8.

    Article  CAS  PubMed  Google Scholar 

  42. Richards BL, Whittle SL, Buchbinder R. Muscle relaxants for pain management in rheumatoid arthritis. Cochrane Database Syst Rev. 2012;1:CD008922.

    PubMed  Google Scholar 

  43. Banzi R, Cusi C, Randazzo C, Sterzi R, Tedesco D, Moja L. Selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) for the prevention of tension-type headache in adults. Cochrane Database Syst Rev. 2015;5:CD011681.

    Google Scholar 

  44. Mersfelder TL, Nichols WH. Gabapentin: abuse, dependence, and withdrawal. Ann Pharmacother. 2016;50(3):229–33.

    Article  CAS  PubMed  Google Scholar 

  45. Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse and diversion: a systematic review. Addiction. 2016;111(7):1160–74.

    Article  PubMed  Google Scholar 

  46. Schjerning O, Pottegård A, Damkier P, Rosenzweig M, Nielsen J. Use of pregabalin—a nationwide pharmacoepidemiological drug utilization study with focus on abuse potential. Pharmacopsychiatry. 2016;49(4):155–61.

    Article  CAS  PubMed  Google Scholar 

  47. Schjerning O, Rosenzweig M, Pottegård A, Damkier P, Nielsen J. Abuse potential of pregabalin: a systematic review. CNS Drugs. 2016;30(1):9–25.

    Article  CAS  PubMed  Google Scholar 

  48. Yuan QL, Guo TM, Liu L, Sun F, Zhang YG. Traditional Chinese medicine for neck pain and low back pain: a systematic review and meta-analysis. PLoS One. 2015;10(2):e0117146.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Tao WW, Jiang H, Tao XM, Jiang P, Sha LY, Sun XC. Effects of acupuncture, tuina, tai chi, qigong, and traditional Chinese medicine five-element music therapy on symptom management and quality of life for cancer patients: a meta-analysis. J Pain Symptom Manag. 2016;51(4):728–47.

    Article  Google Scholar 

  50. Natour J, Cazotti Lde A, Ribeiro LH, Baptista AS, Jones A. Pilates improves pain, function and quality of life in patients with chronic low back pain: a randomized controlled trial. Clin Rehabil. 2015;29(1):59–68.

    Article  PubMed  Google Scholar 

  51. Majchrzycki M, Kocur P, Kotwicki T. Deep tissue massage and nonsteroidal anti-inflammatory drugs for low back pain: a prospective randomized trial. ScientificWorldJournal. 2014;2014:287597.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Sielski R, Rief W, Glombiewski JA. Efficacy of biofeedback in chronic back pain: a meta-analysis. Int J Behav Med. 2016.

  53. Thomas DA, Maslin B, Legler A, Springer E, Asgerally A, Vadivelu N. Role of alternative therapies for chronic pain syndromes. Curr Pain Headache Rep. 2016;20(5):29.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Comprehensive Pain Center, Department of Anesthesiology and Perioperative Medicine, David Geffen School of Medicine, University of California, Los Angeles, CA, USA

    Eric S. Hsu

Authors
  1. Eric S. Hsu
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Eric S. Hsu.

Ethics declarations

Conflict of Interest

Eric S. Hsu declares no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

This article is part of the Topical Collection on Other Pain

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Hsu, E.S. Medication Overuse in Chronic Pain. Curr Pain Headache Rep 21, 2 (2017). https://doi.org/10.1007/s11916-017-0606-z

Download citation

  • Published:

  • DOI: https://doi.org/10.1007/s11916-017-0606-z

Keywords

Search

Navigation