Daily Opioid Use Research Articles

Reduced cold pain tolerance in chronic pain patients following opioid detoxification.

One potential consequence of chronic opioid analgesic administration is a paradoxical increase of pain sensitivity over time. Little scientific attention has been given to how cessation of opioid medication affects the hyperalgesic state. In this study, we examined the effects of opioid tapering on pain sensitivity in chronic pain patients. Twelve chronic pain patients on long-term opioid analgesic treatment were observed in a 7- to 14-day inpatient pain rehabilitation program, with cold pain tolerance assessed at admission and discharge. The majority of participants were completely withdrawn from their opioids during their stay. We hypothesized that those patients with the greatest reduction in daily opioid use would show the greatest increases in pain tolerance, as assessed by a cold pressor task. A linear regression revealed that the amount of opioid medication withdrawn was a significant predictor of pain tolerance changes, but not in the direction hypothesized. Greater opioid reduction was associated with decreased pain tolerance. This reduction of pain tolerance was not associated with opioid withdrawal symptoms or changes in general pain. These findings suggest that the withdrawal of opioids in a chronic pain sample leads to an acute increase in pain sensitivity.

(213) Pain Reduction in Cognitively Impaired Cancer Patients Treated with Olanzapine

Background: Anxiety and cognitive impairment may accompany and aggravate pain. Delirium is extremely common in patients with advanced cancer (up to 85%) and is frequently underdiagnosed. Neuroleptics for the treatment of delirium are standard clinical practice. Their use for pain management remains controversial due to the conflicting reports of their efficacy and their prominent side effects. Olanzapine, an atypical neuroleptic, might offer advantages over traditional neuroleptics because of its safer side effect profile. Also, independent antinociceptive activity of olanzapine was demonstrated in animals and is thought to be mediated by alpha-2 adrenoreceptors, as well as some activity at dopamine and serotonin receptors. Reduction of pain in cognitively impaired cancer pain patients treated with olanzapine has not been previously described. Methods: We present 3 cancer patients with uncontrolled pain who received 2.5 to 5 mg of olanzapine daily to treat mild cognitive impairment and anxiety. Levels of pain, sedation and opioid use were measured 2 days before and 2 days after olanzapine was started. Cognitive function was monitored daily by a psychiatrist using DSM-IV criteria. Results: 2 out of 3 patients were treated with intravenous hydromorphone and 1 intravenous with fentanyl. Cognitive impairment and anxiety resolved within 48 hours in all patients. All 3 patients had marked reduction of the average daily pain scores (from 7 to 1) and an average daily opioid use (64%) without increase in sedation. Discussion: Decreased pain scores and opioid requirements may have resulted from improvement in cognitive function and the known anxiolytic effects of olanzapine or direct or adjuvant analgesic effects of olanzapine. We conclude that olanzapine may be useful as an adjuvant in the treatment of patients with reversible cognitive impairment or severe anxiety and uncontrolled cancer pain. Studies are needed to further evaluate olanzapine's possible independent or opioid synergistic analgesic effect.

Intervertebral Disc Biacuplasty for the Treatment of Lumbar Discogenic Pain: Results of a Six-Month Follow-Up

Intradiscal biacuplasty (IDB) is a novel bipolar cooled radiofrequency system for the treatment of degenerative disk disease. We present the results of a pilot trial with 6-month follow-up. DESIGN, SETTING, PATIENTS, AND INTERVENTIONS: Fifteen patients, 22-55 years old, underwent one- or two-level IDB treatment of their painful lumbar discs. All had chronic low back pain >6 months, back pain exceeding leg pain, concordant pain on provocative discography, disc height >50% of control, and evidence of single- or two-level degenerative disc disease without evidence of additional changes on magnetic resonance imaging. IDB was performed under fluoroscopy using two radiofrequency probes positioned bilaterally in the intervertebral disc. Thirteen patients completed follow-up questionnaires at 1, 3, and 6 months. Pain disability was evaluated with Oswestry and Short Form (SF)-36 questionnaires. Median visual analog scale pain scores were reduced from 7 (95% confidence interval [CI] 6, 8) to 4 (2, 5) cm at 1 month, and remained at 3 (2, 5) cm at 6 months. The Oswestry improved from 23.3 (SD 7.0) to 16.5 (6.8) points at 1 month and remained similar after 6 months. The SF-36 Physical Functioning scores improved from 51 (18) to 70 (16) points after 6 months, while the SF-36 Bodily Pain score improved from 38 (15) to 54 (23) points. Daily opioid use did not change significantly from baseline: from 40 (95% CI 40, 120) before IDB to 5 (0, 40) mg of morphine sulfate equivalent 6 months after IDB. No procedure-related complications were detected. Patients showed improvements in several pain assessment measures after undergoing IDB for discogenic pain. A randomized controlled study is warranted and needed to address the efficacy of the procedure.

Olanzapine in the Management of Cancer Pain

In cancer patients, cognitive impairment, psychological distress, and anxiety may accompany and aggravate pain. Neuroleptics are frequently used to control these symptoms and may be used to treat pain that has been unresponsive to more conventional approaches. Because of prominent side effects of traditional neuroleptics and conflicting data regarding their analgesic efficacy, their use in the treatment of pain remains controversial. Olanzapine, an atypical neuroleptic, might offer advantages because of its safer side effect profile. It has also been shown to have an independent antinociceptive activity in animals. The use of olanzapine in the management of cancer pain has not been previously described. We prospectively collected the data on 8 cancer patients with severe pain, uncontrolled in spite of aggressive opioid titration, who received olanzapine to treat severe anxiety and mild cognitive impairment. Patients did not meet criteria for delirium and their cognitive impairment was defined as cognitive disorder not otherwise specified (NOS) according to DSM-IV. Patients received 2.5 to 7.5 mg of olanzapine daily. In all patients, opioid requirements had escalated rapidly prior to starting olanzapine. Levels of pain, sedation, and opioid use were measured 2 days before and 2 days after olanzapine was started. Cognitive state was assessed daily. All 8 patients had marked reduction of the daily pain scores. The average daily opioid use decreased significantly in all patients. Cognitive impairment and anxiety resolved within 24 hours of initiating olanzapine. In these 8 patients, decreased pain scores and opioid requirements may have resulted from improvement in cognitive function and the known anxiolytic effect of olanzapine. Other mechanisms may include independent or adjuvant analgesic effects of olanzapine. We conclude that olanzapine may be useful in the treatment of patients with uncontrolled cancer pain associated with cognitive impairment or anxiety. Further studies to evaluate possible analgesic effect of olanzapine are needed.

Estimated intelligence and long-term outcomes of opioid addicts.

This study estimated intellectual functioning based upon a demographic profile (DP) for Wechsler Adult Intelligence Scale-Revised (WAIS-R) Full Scale IQ in order to determine its relationship with variables representing initiation, continuation, relapse, and cessation of daily opioid use. The DP Estimated IQs were used to describe a large former opioid addict sample from the 12-year follow-up study of the Drug Abuse Reporting Program (DARP). Results were compared with those from previous studies using meta-analysis. In addition, a correlational analysis was performed. Average DP Estimated IQs for the DARP sample were comparable to mean IQs for both the WAIS-R standardization sample and previous studies. DP Estimated IQ was significantly related to length of addiction career; the higher the estimated IQ, the shorter the career. Other more complex relationships were found for variables used to represent intraindividual factors such as satisfaction with self or family, interpersonal factors such as family or peer influences, and other variables of interest.

Mexican-American heroin addicts.

Next to Blacks, Mexican-Americans are the largest ethnic minority group among the visible opioid addict population in the United States. Although commonly grouped together with Puerto Ricans and other Spanish-speaking peoples under the rubric "Hispanic," Mexican-Americans have a unique culture and ethnohistory. In this report we review the clinical and research literature and present new data from studies of Mexican-American opioid users in San Antonio. Mexican-American addicts tend to use fewer classes of illicit drugs and are less likely to use stimulants and psychedelics than Whites or Blacks. Onset of daily opioid use occurs at an early age, typically around 20, yet first voluntary admission to treatment usually occurs later than it does for other ethnic groups. Mexican-American addicts tend to be arrested more frequently and spend significantly more years in correctional institutions, but there is also evidence that they spend more time voluntarily abstinent and employed during their careers. The duration of the career is prolonged, however, and typically exceeds 20 years. Mexican-Americans prefer individual to group treatment, and are especially unlikely to participate in traditional therapeutic communities and group psychotherapies. The Mexican-American client is the least likely to complete treatment without adverse termination. The literature seems unanimous in calling for more treatment of Mexican-American addicts by Mexican-American therapists, but we found little empirical outcome data which demonstrated that ethnic matching of therapist and client brings better results.

Recidivism among opioid addicts after drug treatment: an analysis by race and tenure in treatment.

Recidivism rates and recidivism proportions for return to a state of daily opioid use following discharge from drug abuse treatment were studied for a sample of Black and White male daily opioid users. The rates and proportions were analyzed by treatment type and time in treatment. Significantly higher recidivism proportions were found for shorter tenure clients.