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Drugs

, Volume 63, Issue 1, pp 17–32 | Cite as

Responsible Prescribing of Opioids for the Management of Chronic Pain

  • Bruce NicholsonEmail author
Therapy In Practice

Abstract

The management of patients with chronic pain is a common clinical challenge. Indeed, chronic pain is often inadequately controlled in patients with cancer and in those with non-cancer chronic pain. Because of the complex nature of chronic pain, successful long-term treatment is more difficult than for acute pain. Most often acute pain is nociceptive, whereas chronic pain can be nociceptive (i.e., in response to noxious stimuli), neuropathic (i.e., initiated by a primary lesion or dysfunction in the nervous system) or mixed in origin.

Opioids are the current standard of care for the treatment of moderate or severe nociceptive pain. Opioids mediate their actions by binding and activating receptors both in the peripheral nervous system and those that are found in inhibitory pain circuits that descend from the midbrain to the spinal cord dorsal horn. Opioid agonists exert a number of physiological responses including analgesia, which increases with increasing doses.

The use of opioids to manage pain in patients with cancer is well accepted. The WHO step-wise algorithm for analgesic therapy based on pain severity reserves the use of opioid therapy for moderate and severe pain. The WHO algorithm has proven to be highly effective for the management of cancer pain. However, the use of opioids to treat patients with chronic non-cancer pain is controversial because of concerns about efficacy and safety, and the possibility of addiction or abuse. The results of clinical surveys and retrospective case series involving patients with non-cancer chronic pain have been inconsistent in regard to resolving these controversial issues.

The oral route of drug administration is most appropriate for patients receiving opioids; although rectal, transdermal and parenteral routes of administration are used in specific situations. For continuous chronic pain, opioids should be administered around-the-clock and several long-acting formulations are available that require administration only once or twice daily. Opioid doses should be titrated according to agent-specific schedules to maximise pain relief and maintain tolerability. Adverse effects include constipation, nausea and vomiting, sedation, cognitive impairment and respiratory depression. Tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%.

Successful pain treatment and symptom management is an attainable goal for the majority of patients with chronic pain. Further controlled clinical trials are needed to define the role of opioid therapy in chronic non-cancer pain, and to establish criteria for patient selection and specific treatment algorithms.

Keywords

Morphine Chronic Pain Neuropathic Pain Cancer Pain Oxycodone 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Acknowledgements

Dr Nicholson has no conflicts of interest directly relevant to the contents of this manuscript but is a consultant and a member of the speakers bureau for Pfizer Inc., Novartis Pharmaceuticals Corporation, Élan Pharmaceutical, Faulding, and Ortho-McNeil, and is a consultant for Medtronic.

References

  1. 1.
    Sriwatanakul K, Weis OF, Alloza JL, et al. Analysis of narcotic analgesic usage in the treatment of postoperative pain. JAMA 1983; 250: 926–9PubMedCrossRefGoogle Scholar
  2. 2.
    Donovan M, Dillon P, McGuire L. Incidence and characteristics of pain in a sample of medical-surgical inpatients. Pain 1987; 30: 69–78PubMedCrossRefGoogle Scholar
  3. 3.
    Daut RL, Cleeland CS. The prevalence and severity of pain in cancer. Cancer 1982; 50: 1913–8PubMedCrossRefGoogle Scholar
  4. 4.
    Grossman SA, Sheidler VR, Swedeen K, et al. Correlation of patient and caregiver ratings of cancer pain. J Pain Symptom Manage 1991; 6: 53–7PubMedCrossRefGoogle Scholar
  5. 5.
    Miaskowski C. Effective cancer pain management: from guidelines to quality improvement. Seattle (WA): International Association for the Study of Pain. 1994Google Scholar
  6. 6.
    Merskey H, Bogduk N, editors. Classification of chronic pain. 2nd ed. Seattle: IASP Press, 1994: 209–14Google Scholar
  7. 7.
    Payne R. Chronic pain: challenges in the assessment and management of cancer pain. J Pain Symptom Manage 2000; 19: S12–5PubMedCrossRefGoogle Scholar
  8. 8.
    Bonica J. General considerations of chronic pain. In: Bonica J, editor. The management of pain. Vol. 1. Philadelphia (PA): Lea and Febiger, 1990: 180–3Google Scholar
  9. 9.
    Siddall PJ, Cousins MJ. Spinal pain mechanisms. Spine 1997; 22: 98–104PubMedCrossRefGoogle Scholar
  10. 10.
    Woolf CJ, Mannion RJ. Neuropathic pain: aetiology, symptoms, mechanisms, and management. Lancet 1999; 353: 1959–64PubMedCrossRefGoogle Scholar
  11. 11.
    Bennett GJ. New frontiers in mechanisms and therapy of painful peripheral neuropathies. Acta Anaesthesiol Sin 1999; 37: 197–203PubMedGoogle Scholar
  12. 12.
    Rohde DS, Detweiler DJ, Basbaum AI. Spinal cord mechanisms of opioid tolerance and dependence: Fos-like immunoreactivity increases in subpopulations of spinal cord neurons during withdrawal. Neuroscience 1996; 72: 233–42PubMedCrossRefGoogle Scholar
  13. 13.
    Schug SA, Large RB. Opioids for chronic noncancer pain. IASP Newsletter 1995; 3: 1–4Google Scholar
  14. 14.
    Watson CP, Babul N. Efficacy of oxycodone in neuropathic pain: a randomized trial in postherpetic neuralgia. Neurology 1998; 50: 1837–41PubMedCrossRefGoogle Scholar
  15. 15.
    Gutstein HB, Akil H. Opioid analgesics. In: Hardman JG, Limbrid LE, Molinoff PB, et al., editors. The pharmacological basis of therapeutics. New York: McGraw-Hill, 2001: 569–619Google Scholar
  16. 16.
    Kieffer BL. Opioids: first lessons from knockout mice. Trends Pharmacol Sci 1999; 20: 19–26PubMedCrossRefGoogle Scholar
  17. 17.
    Stein C. The control of pain in peripheral tissue by opioids. N Engl J Med 1995; 332: 1685–90PubMedCrossRefGoogle Scholar
  18. 18.
    Cherny NI. Opioid analgesics: comparative features and prescribing guidelines. Drugs 1996; 51: 713–37PubMedCrossRefGoogle Scholar
  19. 19.
    Galer BS, Coyle N, Pasternak GW, et al. Individual variability in the response to different opioids: report of five cases. Pain 1992; 49: 87–91PubMedCrossRefGoogle Scholar
  20. 20.
    Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage 1996; 11: 203–17PubMedCrossRefGoogle Scholar
  21. 21.
    Dickinson BD, Altman RD, Nielsen NH, et al. Use of opioids to treat chronic, noncancer pain. West J Med 2000; 172: 107–15PubMedCrossRefGoogle Scholar
  22. 22.
    Large RG, Schug SA. Opioids for chronic pain of non-malignant origin: caring or crippling. Health Care Anal 1995; 3: 5–11PubMedCrossRefGoogle Scholar
  23. 23.
    Dellemijn P. Are opioids effective in relieving neuropathic pain? Pain 1999; 80: 453–62PubMedCrossRefGoogle Scholar
  24. 24.
    Kjaersgaard-Andersen P, Nafei A, Skov O, et al. Codeine plus paracetamol versus paracetamol in longer-term treatment of chronic pain due to osteoarthritis of the hip: a randomised, double-blind, multi-centre study. Pain 1990; 43: 309–18PubMedCrossRefGoogle Scholar
  25. 25.
    Dellemijn PL, van Duijn H, Vanneste JA. Prolonged treatment with transdermal fentanyl in neuropathic pain. J Pain Symptom Manage 1998; 16: 220–9PubMedCrossRefGoogle Scholar
  26. 26.
    Jamison RN, Raymond SA, Slawsby EA, et al. Opioid therapy for chronic noncancer back pain: a randomized prospective study. Spine 1998; 23: 2591–600PubMedCrossRefGoogle Scholar
  27. 27.
    Moulin DE, Iezzi A, Amireh R, et al. Randomised trial of oral morphine for chronic non-cancer pain. Lancet 1996; 347: 143–7PubMedCrossRefGoogle Scholar
  28. 28.
    Arkinstall W, Sandier A, Goughnour B, et al. Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial. Pain 1995; 62: 169–78PubMedCrossRefGoogle Scholar
  29. 29.
    Cherny NI, Thaler HT, Friedlander-Klar H, et al. Opioid responsiveness of cancer pain syndromes caused by neuropathic or nociceptive mechanisms: a combined analysis of controlled, single-dose studies. Neurology 1994; 44: 857–61PubMedCrossRefGoogle Scholar
  30. 30.
    World Health Organization. Cancer pain relief and palliative care: report of a WHO expert committee [World Health Organization Technical Report Series, 804]. Geneva, Switzerland: World Health Organization, 1990: 1–75Google Scholar
  31. 31.
    Jacox AK, Carr DB, Payne R, et al. Managementof cancerpain: clinical practice guideline. Rockville (MD): Agency for Healthcare Policy and Research, 1994Google Scholar
  32. 32.
    Schug SA, Zech D, Dorr U. Cancerpain management according to WHO analgesic guidelines. J Pain Symptom Manage 1990; 5: 27–32PubMedCrossRefGoogle Scholar
  33. 33.
    Zech DF, Grond S, Lynch J, et al. Validation of World Health Organization guidelines for cancer pain relief: a 10-year prospective study. Pain 1995; 63: 65–76PubMedCrossRefGoogle Scholar
  34. 34.
    Haddox JD, Jonanson D, Angarola RT, et al. The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain Medicine and the American Pain Society. Clin J Pain 1997; 13: 6–8CrossRefGoogle Scholar
  35. 35.
    Practice guidelines for chronic pain management: a report by the American Society of Anesthesiologists Task Force on Pain Management, Chronic Pain Section. Anesthesiology 1997; 86: 995–1004CrossRefGoogle Scholar
  36. 36.
    Schug SA, Ritchie JE. Use of opioids in chronic pain of non-malignant origin. New Ethicals J 1999 Dec, 37-45Google Scholar
  37. 37.
    Ashburn MA. APS must advocate for policy improvements [letter]. Am Pain Soc Bull 2001 Mar/Apr; 11: 2Google Scholar
  38. 38.
    Broomhead A, Kerr R, Tester W, et al. Comparison of a once-a-day sustained-release morphine formulation with standard oral morphine treatment for cancer pain. J Pain Symptom Manage 1997; 14: 63–73PubMedCrossRefGoogle Scholar
  39. 39.
    Sweetman SC, editor. Martindale: the complete drug reference. 33rd ed. London: Pharmaceutical Press, 2002: 56Google Scholar
  40. 40.
    Gourlay GK. Sustained relief of chronic pain: pharmacokinetics of sustained release morphine. Clin Pharmacokinet 1998; 35: 173–90PubMedCrossRefGoogle Scholar
  41. 41.
    Parris WC, Johnson Jr BW, Croghan MK, et al. The use of controlled-release oxycodone for the treatment of chronic cancer pain: a randomized, double-blind study. J Pain Symptom Manage 1998; 16: 205–11PubMedCrossRefGoogle Scholar
  42. 42.
    Duragesic® Prescribing Information. In: Physician's Desk Reference. Montvale (NJ): Medical Economics, 2001: 1573Google Scholar
  43. 43.
    Ahmedzai S, Brooks D. Transdermal fentanyl versus sustained-release oral morphine in cancer pain: preference, efficacy, and quality of life. The TTS-Fentanyl Comparative Trial Group. J Pain Symptom Manage 1997; 13: 254–61CrossRefGoogle Scholar
  44. 44.
    Milligan K, Lanteri Minet M, Borchert K, et al. Evaluation of long-term efficacy and safety of transdermal fentanyl in the treatment of chronic noncancer pain. J Pain 2001; 2: 197–204PubMedCrossRefGoogle Scholar
  45. 45.
    Gordon DB, Stevenson KK, Griffie J, et al. Opioid equianalgesic calculations. J Palliat Med 1999; 2: 209–17PubMedCrossRefGoogle Scholar
  46. 46.
    Campora E, Merlini L, Pace M, et al. The incidence of narcotic-induced emesis. J Pain Symptom Manage 1991; 6: 428–30PubMedCrossRefGoogle Scholar
  47. 47.
    Aparasu R, McCoy RA, Weber C, et al. Opioid-induced emesis among hospitalized nonsurgical patients: effect on pain and quality of life. J Pain Symptom Manage 1999; 18: 280–8PubMedCrossRefGoogle Scholar
  48. 48.
    PDQ® Cancer information summaries: supportive care. Pain: National Cancer Institute [online]. Available from URL: http://www.cancer.gov/cancer_information/doc_pdq.aspx?.version=provider&viewid=66d23623-3e9c-4bcf-8c09-902c2afe0f06 [Accessed 2002 May 10]
  49. 49.
    Galski T, Williams JB, Ehle HT. Effects of opioids on driving ability. J Pain Symptom Manage 2000; 19: 200–8PubMedCrossRefGoogle Scholar
  50. 50.
    Vainio A, Ollila J, Matikainen E, et al. Driving ability in cancer patients receiving long-term morphine analgesia. Lancet 1995; 346: 667–70PubMedCrossRefGoogle Scholar
  51. 51.
    Compton P, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and “problematic” substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998; 16: 355–63PubMedCrossRefGoogle Scholar
  52. 52.
    Robinson RC, Gatchel RJ, Polatin P, et al. Screening for problematic prescription opioid use. Clin J Pain 2001; 17: 220–8PubMedCrossRefGoogle Scholar
  53. 53.
    Joranson DE, Ryan KM, Gilson AM, et al. Trends in medical use and abuse of opioid analgesics. JAMA 2000; 283: 1710–4PubMedCrossRefGoogle Scholar
  54. 54.
    Leow KP, Smith MT, Williams B, et al. Single-dose and steady-state pharmacokinetics and pharmacodynamics of oxycodone in patients with cancer. Clin Pharmacol Ther 1992; 52: 487–95PubMedCrossRefGoogle Scholar
  55. 55.
    Poyhia R, Seppala T, Olkkola KT, et al. The pharmacokinetics and metabolism of oxycodone after intramuscular and oral administration to healthy subjects. Br J Clin Pharmacol 1992; 33: 617–21PubMedCrossRefGoogle Scholar
  56. 56.
    Dilaudid® Prescribing Information. In: Physician's Desk Reference. Montvale (NJ): Medical Economics, 2001: 1618Google Scholar
  57. 57.
    MS Contin® Prescribing Information. In: Physician's Desk Reference. Montvale (NJ): Medical Economics, 2001: 2680Google Scholar
  58. 58.
    Oxycontin® Prescribing Information. In: Physician's Desk Reference. Montvale (NJ): Medical Economics, 2001: 2697Google Scholar
  59. 59.
    Gourlay GK, Cherry DA, Onley MM, et al. Pharmacokinetics and pharmacodynamics of twenty-four-hourly Kapanol compared to twelve-hourly MS Contin in the treatment of severe cancer pain. Pain 1997; 69: 295–302PubMedCrossRefGoogle Scholar
  60. 60.
    Gourlay GK, Plummer JL, Cherry DA, Onley MM. A comparison of Kapanol (a new sustained-release morphine formulation), MST Continus, and morphine solution in cancer patients: pharmacokinetic aspects of morphine and morphine metabolites. In: Gebhart GF, Hammond DL, Jensen TS, editors. Proceedings of the 7th World Congress on Pain, progress in pain research and management. Vol 2. Seattle (WA): IASP Press, 1994: 631–43Google Scholar
  61. 61.
    Ebert B, Andersen S, Krogsgaard-Larsen P. Ketobemidone, methadone and pethidine are non-competitive N-methyl-D-aspartate (NMDA) antagonists in the rat cortex and spinal cord. Neurosci Lett 1995; 187: 165–8PubMedCrossRefGoogle Scholar
  62. 62.
    Cleeland CS, Gonin R, Hatfield AK. Pain and its treatment in outpatients with metastatic cancer. N Engl J Med 1994; 330: 592–6PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2003

Authors and Affiliations

  1. 1.Division of Pain Medicine/HospiceLehigh Valley Hospital/Health NetworkAllentownUSA

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