Treatment Of Chronic Noncancer Pain Research Articles

P.6.c.006 Anxiety and depressive symptoms or disorders in patients with cannabis dependence without major psychiatric disorders

The prevalence of opioid-associated morbidity and mortality underscores the need for research on non-opioid treatments for chronic non-cancer pain (CNCP). Pain is the most common medical condition for which patients request medical cannabis. Limited research indicates that patients are interested in cannabis as a potential addition to or replacement for opioid medication. This analysis reports on CNCP patient and clinician perceptions about the co-use of cannabis and opioids for CNCP management.We interviewed 23 clinicians and 46 CNCP patients, using semi-structured interview guides, from six safety-net clinics across the San Francisco Bay Area, and 5 key stakeholders involved in CNCP management. We used a modified grounded theory approach to code and analyze transcripts.CNCP patients described potential benefits of co-use of cannabis and opioids for pain management and concerns about dosing and addictive potential. Patients reported seeking cannabis when unable to obtain prescription opioids. Clinicians stated that their patients reported cannabis being helpful in managing pain symptoms. Clinicians expressed concerns about the potential exacerbation of mental health issues resulting from cannabis use.Clinicians are hampered by a lack of clinically relevant information about cannabis use, efficacy and side-effects. Currently no guidelines exist for clinicians to address opioid and cannabis co-use, or to discuss the risk and benefits of cannabis for CNCP management, including side effects. Cannabis and opioid co-use was commonly reported by patients in our sample, yet rarely addressed during clinical CNCP care. Further research is needed on the risks and benefits of cannabis and opioid co-use.

Patient Selection and Outcomes Using a LowDose Intrathecal Opioid Trialing Method for Chronic Nonmalignant Pain

Background: Various methods exist for trialing patients for intrathecal drug delivery. Currently no standards exist regarding “best practices” for trialing techniques. Objectives: The specific aim of the current study is to report results of patients trialed using a low-dose intrathecal morphine technique in the treatment of chronic noncancer pain. Setting: academic pain medicine practice Study Design: Retrospective Review Method: Visual analog pain scores (VAS) were obtained at the initial visit, after a 6 week opioid-free interval prior to trial, at intrathecal doses of 25, 50, 100, 200 and 400 µg of intrathecal morphine during the trial, at one month post-implant, and current VAS. Additionally, intrathecal opioid doses at implant and current state are reported. Results: VAS scores at the initial visit and after 6 weeks of opioid cessation were identical. There was a significant improvement in VAS after the trial, which was sustained over the course of therapy. Additionally, the use of the protocol described in this article suggests that the doseresponse relationship following opioid cessation is in the 50-400 µg/d range for intrathecal morphine and that tolerance may be reversed during the 6 week opioid-free period. Limitations: Small trialing study Conclusions: Opioid taper and a 6 week opioid-free period may 1) improve long-term analgesia versus a combination of oral/ intrathecal drug delivery system therapy 2) it may be possible to maintain analgesia at microgram doses and 3) opioid tolerance may be reversible in 6 weeks. Further it appears that a dose response relationship for effective analgesia may be less than 400 µg of intrathecal morphine. Key Words: Intrathecal opioids, intrathecal drug delivery, oral opioid therapy, chronic noncancer pain

Primary care providers' perspective on prescribing opioids to older adults with chronic non-cancer pain: A qualitative study

BackgroundThe use of opioid medications as treatment for chronic non-cancer pain remains controversial. Little information is currently available regarding healthcare providers' attitudes and beliefs about this practice among older adults. This study aimed to describe primary care providers' experiences and attitudes towards, as well as perceived barriers and facilitators to prescribing opioids as a treatment for chronic pain among older adults.MethodsSix focus groups were conducted with a total of 23 physicians and three nurse practitioners from two academically affiliated primary care practices and three community health centers located in New York City. Focus groups were audiotape recorded and transcribed. The data were analyzed using directed content analysis; NVivo software was used to assist in the quantification of identified themes.ResultsMost participants (96%) employed opioids as therapy for some of their older patients with chronic pain, although not as first-line therapy. Providers cited multiple barriers, including fear of causing harm, the subjectivity of pain, lack of education, problems converting between opioids, and stigma. New barriers included patient/family member reluctance to try an opioid and concerns about opioid abuse by family members/caregivers. Studies confirming treatment benefit, validated tools for assessing risk and/or dosing for comorbidities, improved conversion methods, patient education, and peer support could facilitate opioid prescribing. Participants voiced greater comfort using opioids in the setting of delivering palliative or hospice care versus care of patients with chronic pain, and expressed substantial frustration managing chronic pain.ConclusionsProviders perceive multiple barriers to prescribing opioids to older adults with chronic pain, and use these medications cautiously. Establishing the long-term safety and efficacy of these medications, generating improved prescribing methods, and implementing provider and patient educational interventions could help to improve the management of chronic pain in later life.

Breakthrough Pain in Chronic Non-Cancer Pain: Fact, Fiction, or Abuse

Treatment of chronic non-cancer pain with opioid therapy has escalated in recent years, resulting in exploding therapeutic use and misuse of prescription opioids and multiple adverse drug events. Breakthrough pain is defined as a transient exacerbation of pain experienced by individuals who have relatively stable and adequately controlled baseline cancer pain. Further, the definition of breakthrough pain, prevalence, characteristics, implications, and treatment modalities have been extensively described for chronic cancer pain. However, the literature for breakthrough pain in chronic non-cancer pain including its terminology, prevalence, relevance, characteristics, and treatments, have been poorly described and continue to be debated. The philosophy of breakthrough pain in chronic non-cancer pain raises multiple issues leading almost all patients to be on high dose long-acting opioids, followed by supplementing with short-acting drugs, instead of treating the patients with only shortacting drugs as required. Consequently, the subject of breakthrough pain in chronic non-cancer pain is looked at with suspicion due to the lack of evidence and inherent bias associated with its evaluation, followed by escalating use and abuse of opioids. Multiple issues related to the concept of breakthrough pain in chronic non-cancer pain evolve around extensive use, overuse, misuse, and abuse of opioids. In the era of eliminating opioids or significantly curtailing their use to only appropriate indications, the concept of breakthrough pain raises multiple questions without any scientific evidence. This review illustrates that there is no significant evidence for any type of breakthrough pain in chronic non-cancer pain based on available literature, methodology utilized, and response to opioids in chronic non-cancer pain. The advocacy for increased usage of opioids in the treatment of chronic pain dates back to the liberalization of laws governing opioid prescription for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and is exploding with new pain management standards for inpatient and outpatient medical care implemented by the Joint Commission on Accreditation of Health Care Organizations in 2000, and the advocacy by many physicians and organizations for increased use of opioids. This comprehensive review critically evaluates the available evidence of breakthrough pain in chronic non-cancer pain including its existence, prevalence, and managing symptoms which are described as breakthrough pain or episodic pain. Key words: Breakthrough pain, opioids, chronic non-cancer pain, opioid abuse, opioid misuse, addiction, opioid hyperalgesia, interventional techniques

A Systematic Review of Randomized Trials of Long-Term Opioid Management for Chronic Non-Cancer Pain

Background: Even though opioids have been used for pain for thousands of years, opioid therapy for chronic non-cancer pain is controversial due to concerns regarding the long-term effectiveness and safety, particularly the risk of tolerance, dependance, or abuse. While the debate continues, the use of chronic opioid therapy for chronic non-cancer pain has increased exponentially. Even though evidence is limited, multiple expert panels have concluded that chronic opioid therapy can be effective therapy for carefully selected and monitored patients with chronic non-cancer pain. Study Design: A systematic review of randomized trials of opioid management for chronic noncancer pain. Objective: The objective of this systematic review is to evaluate the clinical efficacy of opioids in the treatment of chronic non-cancer pain. Methods: A comprehensive evaluation of the literature relating to opioids in chronic non-cancer pain was performed. The literature was evaluated according to Cochrane review criteria for randomized controlled trials (RCTs) and Jadad criteria. A literature search was conducted by using PubMed, EMBASE, Cochrane library, ECRI Institute Library, U.S. Food and Drug Administration (FDA) website, U.S. National Guideline Clearinghouse (NGC), Database of Abstracts of Reviews of Effectiveness (DARE), clinical trials, systematic reviews and cross references from systematic reviews. The level of evidence was classified as good, fair, or poor based on the quality of evidence developed by the United States Preventive Services Task Force (USPSTF) and used by other systematic reviews and guidelines. Outcome Measures: Pain relief was the primary outcome measure. Other outcome measures were functional improvement, withdrawals, and adverse effects. Results: Based on the USPSTF criteria, the indicated level of evidence was fair for Tramadol in managing osteoarthritis. For all the drugs assessed, including Tramadol, for all other conditions, the evidence was poor based on either weak positive evidence, indeterminate evidence, or negative evidence. Limitations: A paucity of literature, specifically with follow-up beyond 12 weeks for all types of opioids with controlled trials for various chronic non-cancer pain conditions. Conclusions: This systematic review illustrated fair evidence for Tramadol in managing osteoarthritis with poor evidence for all other drugs and conditions. Thus, recommendations must be based on non-randomized studies. Key words: Chronic non-cancer pain, opioids, opioid efficacy, opioid effectiveness, significant pain relief, functional improvement, adverse effects, morphine, hydrocodone, hydromorphone, fentanyl, tramadol, buprenorphine, methadone, tapentadol, oxycodone, oxymorphone, systematic reviews, randomized trials

Outcomes Associated with Opioid Use in the Treatment of Chronic Noncancer Pain in Older Adults: A Systematic Review and Meta-Analysis

Outcomes Associated with Opioid Use in the Treatment of Chronic Noncancer Pain in Older Adults: A Systematic Review and Meta-Analysis

Transdermal Buprenorphine for the Treatment of Chronic Noncancer Pain in the Oldest Old

Context Chronic pain increases with age, and in the elderly, comorbidities and polypharmacotherapy make the choice of treatment for pharmacological pain control a complex matter. Objectives We conducted a multicenter, prospective, observational study to evaluate the efficacy and safety of the buprenorphine transdermal delivery system (TDS) in elderly patients with chronic noncancer pain. The aim was to assess the cognitive and behavioral status of patients during treatment. Methods The study included 93 patients (69 women and 24 men); the mean age was 79.7 years, and in most cases, the pain was due to osteoarthritis. Almost three-quarters (74.2%) of the patients had suffered pain for more than 12 months. The treatment was buprenorphine TDS, starting from a dose of 17.5 μg/h. Outcomes were assessed using the Mini-Mental State Examination (MMSE), the 17-item Hamilton Depression scale (HAM-D 17), the Neuropsychiatric Inventory, the Barthel Index, the Short-Form Health Survey (SF-12), a verbal numeric rating scale, and the Cumulative Illness Rating Scale (CIRS). Results Buprenorphine treatment was associated with a decrease in pain severity without negative effects on the central nervous system. On the HAM-D scale, there were reductions in both the psychological and somatic scores. On the MMSE, values at the beginning and end of the study were comparable. Evaluation by SF-12 showed improvements in physical and mental status. CIRS values at baseline and at the end of the study were superimposable, indirectly confirming the tolerability and safety profile of the drug. Conclusion Our experience confirms the analgesic activity and safety of buprenorphine TDS in the elderly. There was an improvement in mood and a partial resumption of activities, with no influence on cognitive and behavioral ability.

Primary Care Providers’ Judgments of Opioid Analgesic Misuse in a Community-Based Cohort of HIV-Infected Indigent Adults

BACKGROUNDPrimary care providers (PCPs) must balance treatment of chronic non-cancer pain with opioid analgesics with concerns about opioid misuse.OBJECTIVEWe co-enrolled community-based indigent adults and their PCPs to determine PCPs’ accuracy of estimating opioid analgesic misuse and illicit substance use.DESIGNPatient-provider dyad study.PARTICIPANTSHIV-infected, community-based indigent adults (‘patients’) and their PCPs.MAIN MEASURESUsing structured interviews, we queried patients on use and misuse of opioid analgesics and illicit substances. PCPs completed patient- and provider-specific questionnaires. We calculated the sensitivity, specificity, and measures of agreement between PCPs’ judgments and patients’ reports of opioid misuse and illicit substance use. We examined factors associated with PCPs’ thinking that their patients had misused opioid analgesics and determined factors associated with patients’ misuse.KEY RESULTSWe had 105 patient-provider dyads. Of the patients, 21 had misused opioids and 45 had used illicit substances in the past year. The sensitivity of PCPs’ judgments of opioid analgesic misuse was 61.9% and specificity, 53.6% (Kappa score 0.09, p = 0.10). The sensitivity of PCPs’ judgments of illicit substance use was 71.1% and specificity, 66.7% (Kappa score 0.37, p <0.001). PCPs were more likely to think that younger patients (Adjusted odds ratio (AOR) 0.89, 95% CI 0.84-0.97), African American patients (AOR 2.53, 95% CI 1.05-6.07) and those who had used illicit substances in the past year (AOR 3.33, 95% CI 1.35-8.20) had misused opioids. Younger (AOR 0.94, 95% CI 0.86-1.02) and African American (AOR 0.71, 95% CI 0.25-1.97) patients were not more likely to report misuse, whereas persons who had used illicit substances were (AOR 3.01, 95% CI 1.04-8.76).CONCLUSIONPCPs’ impressions of misuse were discordant with patients’ self-reports of opioid analgesic misuse. PCPs incorrectly used age and race as predictors of misuse in this high-risk cohort.

Numerous Studies Show Urine Drug Testing A Critical Tool in Treatment of Chronic Noncancer Pain

Numerous Studies Show Urine Drug Testing A Critical Tool in Treatment of Chronic Noncancer Pain

Opioid use in chronic noncancer pain: guidelines revisited

The treatment of chronic noncancer pain with opioids is controversial. This review aims to find answers to three questions patients and physicians might have: how much (pain relief can be expected), how long (will pain relief be sustained) and how bad (are side-effects)? To this end, we reviewed the second generation of clinical guidelines on this topic. These are based on a significantly higher number of randomized controlled trials than former ones and, therefore, allow evidence-based statements. Six guidelines have been launched recently to improve care and safety when treating chronic noncancer pain with opioids. The evidence base for long-term administration of opioids is weak, mostly due to methodological flaws in the available studies and because opioids have no superior effects compared with other analgesics. The maximum pain relief attributable to opioid or nonsteroidal anti-inflammatory drug administration for up to 3 months is 8-12 out of 100 units. It is doubtful that this is clinically important for patients with chronic noncancer pain. Even selected 'responders' from previous randomized controlled trials do not report noticeable pain relief. The small effect-size differences between the classes of analgesic drugs do not provide a basis for differential therapeutic decisions. Many guideline panels concentrate their recommendations solely on safety of opioid analgesics and patients are usually not informed about the (low) degree of pain relief to be expected. This makes adherence of patients unlikely. Beyond that, multimodal treatment of chronic noncancer pain should become the center of attention.

Therapeutic Use, Abuse, and Nonmedical Use of Opioids: A Ten-Year Perspective

The treatment of chronic pain, therapeutic opioid use and abuse, and the nonmedical use of prescription drugs have been topics of intense focus and debate. After the liberalization of laws governing opioid prescribing for the treatment of chronic non-cancer pain by state medical boards in the late 1990s, and with the introduction of new pain management standards implemented by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) in 2000, opioids, in general, and the most potent forms of opioids including Schedule II drugs, in particular, have dramatically increased. Despite the escalating use and abuse of therapeutic opioids, nearly 15 to 20 years later the scientific evidence for the effectiveness of opioids for chronic non-cancer pain remains unclear. Concerns continue regarding efficacy; problematic physiologic effects such as hyperalgesia, hypogonadism and sexual dysfunction; and adverse side effects - especially the potential for misuse and abuse - and the increase in opioid-related deaths. Americans, constituting only 4.6% of the world's population, have been consuming 80% of the global opioid supply, and 99% of the global hydrocodone supply, as well as two-thirds of the world's illegal drugs. Retail sales of commonly used opioid medications (including methadone, oxycodone, fentanyl base, hydromorphone, hydrocodone, morphine, meperidine, and codeine) have increased from a total of 50.7 million grams in 1997 to 126.5 million grams in 2007. This is an overall increase of 149% with increases ranging from 222% for morphine, 280% for hydrocodone, 319% for hydromorphone, 525% for fentanyl base, 866% for oxycodone, to 1,293% for methadone. Average sales of opioids per person have increased from 74 milligrams in 1997 to 369 milligrams in 2007, a 402% increase. Surveys of nonprescription drug abuse, emergency department visits for prescription controlled drugs, unintentional deaths due to prescription controlled substances, therapeutic use of opioids, and opioid abuse have been steadily rising. This manuscript provides an updated 10-year perspective on therapeutic use, abuse, and non-medical use of opioids and their consequences.

Ketamine for the treatment of chronic non-cancer pain

Importance of the field: Worldwide the number of patients affected by chronic pain is growing and conventional treatment is often insufficient. Recently the importance of the N-methyl-d-aspartate receptor (NMDAR) in the mechanisms and maintenance of chronic pain was established. Ketamine (introduced in the 1960s as an anesthetic) is the most studied NMDAR antagonist in the treatment of various chronic pain syndromes.Areas covered in this review: The pharmacology, safety and toxicology of ketamine are discussed. Further, electronic databases were scanned for prospective, randomized controlled trials that assessed ketamine's analgesic effect in patients with chronic pain. The focus of this review is on trials published after 2008 that applied long-term intravenous infusions.What the reader will gain: While most studies on intravenous ketamine show acute analgesic effects, three recent trials on long-term ketamine treatment (days to weeks) demonstrate the effectiveness of ketamine in causing long-term (months) relief of chronic pain. Despite these positive results, further studies are needed on safety/toxicity issues. Other administration modes are less effective in causing long-term pain relief.Take home message: There is now evidence form a limited number of studies that pain relief lasting for months is observed after long-term intravenous ketamine infusion, suggesting a modulatory effect of ketamine in the process of chronic pain, possibly via blockade of upregulated NMDAR.

Outcomes Associated with Opioid Use in the Treatment of Chronic Noncancer Pain in Older Adults: A Systematic Review and Meta‐Analysis

This systematic review summarizes existing evidence regarding the efficacy, safety, and abuse and misuse potential of opioids as treatment for chronic noncancer pain in older adults. Multiple databases were searched to identify relevant studies published in English (1/1/80-7/1/09) with a mean study population age of 60 and older. Forty-three articles were identified and retained for review (40 reported safety and efficacy data, the remaining 3 reported misuse or abuse outcome data). The weighted mean subject age was 64.1 (mean age range 60-73). Studies enrolled patients with osteoarthritis (70%), neuropathic pain (13%), and other pain-producing disorders (17%). The mean duration of treatment studies was 4 weeks (range 1.5-156 weeks), and only five (12%) lasted longer than 12 weeks. In meta-analyses, effect sizes were -0.557 (P<.001) for pain reduction, -0.432 (P<.001) for physical disability reduction, and 0.859 (P=.31) for improved sleep. The effect size for the Medical Outcomes Study 36-item Health Survey was 0.191 (P=.17) for the physical component score and -0.220 (P=.04) for the mental component score. Adults aged 65 and older were as likely as those younger than 65 to benefit from treatment. Common adverse events included constipation (median frequency of occurrence 30%), nausea (28%), and dizziness (22%) and prompted opioid discontinuation in 25% of cases. Abuse and misuse behaviors were negatively associated with older age. In older adults with chronic pain and no significant comorbidity, short-term use of opioids is associated with reduction in pain intensity and better physical functioning but poorer mental health functioning. The long-term safety, efficacy, and abuse potential of this treatment practice in diverse populations of older persons remain to be determined.

Randomized Trial of Web-based Training About Opioid Therapy for Chronic Pain

The treatment of chronic noncancer pain with chronic opioid therapy has increased rapidly, but medicine residents receive little training concerning this therapy. Therefore we conducted a trial to determine if an interactive web-based training focusing on shared decision-making for chronic opioid therapy improves knowledge and competence compared with exposure to practice guidelines. A randomized controlled educational trial of 213 internal medicine residents from 5 medicine residencies participating in the Residency Review Committee for Internal Medicine's Educational Innovations Project comparing access to interactive web-based training (COPE: Collaborative Opioid Prescribing Education) or access to the Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain. Pretraining and immediate posttraining knowledge test; pretraining and 60-day posttraining self-reported competence, satisfaction, patient-centeredness, and selected clinical behaviors were analyzed using t tests, Pearson chi, and Generalized Estimating Equations. The web training group had greater increase in knowledge with training (chi(2)=72.06, P<0.00001) and greater self-rated competence in the management of outpatients with chronic pain (chi(2)=6.48, P=0.01), and specifically in the use of opioids in this management (chi(2)=5.17, P=0.02). Residents in both groups reported more satisfaction with managing chronic pain care after training (chi(2)=52.72, P<0.0001), though the web training was superior on subscales concerning training adequacy (chi(2)=4.94, P=0.026) and relationship quality (chi(2)=5.79, P=0.016). Exposure to an interactive web-based training focused on shared decision-making and communication skills was more effective than exposure to compatible practice guidelines for knowledge and self-reported competence in the management of chronic noncancer pain.

Characteristics of Older Adults Receiving Opioids in Primary Care: Treatment Duration and Outcomes

To describe characteristics of older adults who received opioids for chronic non-cancer pain (CP), ascertain types of opioid treatments received, and examine associations between patient characteristics and treatment outcomes. Retrospective cohort study. Primary care practice in New York City. Eligible patients were >or=65 and newly started on an opioid for CP. Patient characteristics and provider treatments, as well as duration of opioid therapy, proportion discontinuing therapy, and evidence of pain reduction and continued use of opioid for more than 1 year. Other outcomes included the presence and type(s) of side effects, abuse/misuse behaviors, and adverse events. Participants (N = 133) had a mean age of 82 (range = 65-105), were mostly female (84%), and white (74%). Common indications for opioid treatment included back pain (37%) and osteoarthritis (35%). Mean duration of opioid use was 388 days (range = 0-1,880). Short-acting analgesics were most commonly prescribed. Physicians recorded side effects in 40% of cases. Opioids were discontinued in 48% of cases, mostly due to side effects/lack of efficacy. Pain reduction was documented in 66% of patient records, while 32% reported less pain and continued treatment for >or=1 year. Three percent displayed abuse/misuse behaviors, and 5% were hospitalized due to opioid-related adverse events. Over 50% of older patients with CP tolerated treatment. Treatment was discontinued in 48% of cases, mostly due to side effects and lack of analgesic efficacy. Efforts are needed to establish the long-term safety and efficacy of opioid treatment for CP in diverse older patient populations.

Oral Aloe vera as a treatment for osteoarthritis: a summary

While pain relief is a basic tenet of health care, pain is under-treated in the UK (Davies and Mcvicar, 2000) and this issue remains unresolved. This paper suggests that oral Aloe vera could be used in the treatment of chronic non-cancer pain (CNCP), particularly that caused by osteoarthritis (OA). Despite being used as arthritis treatment for centuries (Yoo et al, 2008), evidence of effectiveness of Aloe vera is anecdotal or from small studies. The perceived benefits of prescribing Aloe vera for OA may be twofold: it has utility as an anti-inflammatory agent and also as a prophylactic against the gastrointestinal irritant effects of non-steroidal anti-inflammatory drugs (NSAIDs). Long-term, randomized, controlled studies are still needed to address the lack of evidence informing optimum prescribing of pain medication for people with OA (Cowan, 2007). There is no reason that so called 'nutraceutical' agents should not be subjected to the same rigorous randomized, controlled, double-blind trials as other 'mainstream' drugs. Therefore, it is appropriate to ask whether NSAID treatment and side effects can be improved by the addition of oral Aloe vera. Thus, we may then be in a more informed position to resolve the ongoing 'Pandemonium over Painkillers' (Cowan, 2007).

Importance of Urine Drug Testing in the Treatment of Chronic Noncancer Pain: Implications of Recent Medicare Policy Changes in Kentucky

Background: Urine drug testing has become a widely used tool in American society for deterring illicit drug use. In the practice of medicine, urine drug testing is commonly used to help diagnose substance misuse, abuse, or addiction. Objective: This narrative review provides an informed perspective on the importance of urine drug testing in the medical treatment of chronic noncancer pain. The history and current uses of urine drug tests in the United States are reviewed, the prevalence and nature of prescription drug misuse is described as is related to chronic noncancer pain, and implications and considerations for practitioners are presented related to the noncancer pain diagnosis and treatment. Discussion: Practitioners are confronted with the ethical and legal dilemma of being called to adequately treat chronic pain in a culture with a high prevalence of prescription drug abuse. Yet the symptoms of drug abuse are nonspecific and therefore of limited value to the practitioner in determining patient compliance to drug treatment regimens. In contrast, urine drug testing has a reliable history, both in and out of medicine, as an independent sign of drug misuse. This sign can be used to aid in the diagnosis and treatment of drug misuse and underlying addictions to improve patient outcomes. Conclusion: Regular urine drug testing should be a part of acute and chronic pain management whether or not the patient has any signs or symptoms of drug misuse. Key words: chronic noncancer pain, Medicare, Medicaid, urine drug testing, opioids, drug abuse

Opioid Dependence: Managing the High Cost of Treatment Failure

BackgrOunD: The use of opioids for chronic noncancer pain increased 222% from 1992 to 2002. Opioid dependence has also increased significantly, leading to a burden on patients, employers, insurers, society, and the entire health care system. It is imperative that opioid dependence is addressed and treated properly, in order to return patients to being productive participants in the workplace and society. OBjecTIve: To provide an overview of addiction, abuse, and dependence and identify risk factors for addiction. Summary: Studies have shown that intensive use of opioids is associated with increased utilization of costly health care services, prolonged disability, and continued use of opioids, leading to abuse and dependence in many patients. While identifying patients at risk for developing opioid dependence is difficult, there are many risk stratification tools now available to practitioners, including the Opioid risk Tool (OrT) or Screener and Opioid assessment for Patients with Pain (SOaPP). understanding the differences between dependence, addiction, and tolerance is essential to managing patients on opioids. cOncLuSIOn: It is imperative that patients be properly managed when being treated for pain. Physicians and employers have to be able to identify patients at risk for opioid abuse or exhibiting symptoms of opioid abuse and know how to address their needs. J Manag Care Pharm. 2010;16(1-b):S4-S8 copyright © 2010, academy of managed care Pharmacy. all rights reserved. SAIRA A. JAN, MS, PharmD, is Clinical Director, Blue Cross Blue Shield of New Jersey, and Associate Professor at the Ernest Mario School of Pharmacy of Rutgers, the State University of New Jersey. AUTHOR CORRESPONDENCE: Saira A. Jan, MS, PharmD, Director of Clinical Pharmacy Management, Horizon Blue Cross Blue Shield of New Jersey, Newark, NJ 07105-2200. Tel.: 973.466.6192; Fax: 973.466.4665. E-mail: Saira_ Jan@horizon-bcbsnj.com. Author Drug abuse and dependence are on the rise. The widespread use of opioid analgesics for the treatment of chronic noncancer pain and for acute pain management began in the late 1980s. Between 1980 and 2000, there was an increase from 8% to 16% in the number of patients receiving opioids for chronic musculoskeletal pain and an increase in use from 8% to 11% for acute musculoskeletal pain.1,2 In 2002, reports show a 222% increase in the absolute number or prescriptions for opioid narcotics over the previous 10-year period.1,3 Today, the most common method for treating chronic pain is with the use of prescription analgesics, including opioids.4 In the 1970s, chronic pain patients were encouraged by society to avoid opioids due to concerns that taking opioids invariably led to addiction.5 In the early 1980s, the pendulum shifted to widespread use of opioids, based on results of a small study (n = 20) showing chronic pain patients could benefit from pain control using opioids with little risk of developing dependence.6,7,8,9 Additionally, in the 1990s, a review article of several studies showed patients with neuropathic pain experienced relief from opioids.6,8,9 Unfortunately, many patients continue to take opioids despite inadequate pain control. Patients on chronic narcotic pain medications generate higher costs of health care, have higher surgery rates, a greater level of disability, and higher rates of late opioid use.10 Late opioid use is defined as receiving ≥ 5 opioid prescriptions between 30 and 730 days after onset of pain, a quantity of prescriptions that is generally beyond what is considered appropriate use for symptom control for an acute pain exacerbation.1 In a retrospective cohort study of 8,443 workers’ compensation claims for acute disabling lower back pain, looking at claims from January 1, 2002, and December 31, 2003, intensive use of opioids early in treatment was associated with worse long-term outcomes, increased use of costly medical services (including surgery), prolonged disability, and continued use of opioids.1 One dilemma that arises with using opioids long term is that hyperalgesia (increased pain sensitivity), decreased libido and other hormonal effects, and depression may occur, as well as tolerance. Statistics have shown that at least 1 of these effects is experienced by 51% of all patients taking oral opioids.2 Another concern is the risk of dependence and addiction. For most of the twentieth century, opioid dependence has been problematic.11 A review of 24 studies (2,507 chronic pain patients) have shown that there is a 3.3% risk of developing addiction.6 While this percentage is low, it represents a large population that is hard to manage. Evaluating and re-evaluating patients who are at higher risk of developing addiction is something that all clinicians treating chronic pain patients treated with opioids should be performing on an ongoing basis.6

Opioid Endocrinopathy: A Clinical Problem in Patients With Chronic Pain and Long-term Oral Opioid Treatment

The use of strong opioids for treatment of noncancer chronic pain has increased. However, strong evidence for sustained pain relief and improved function is lacking. Controversy prevails, whether hormonal changes are induced by long-term treatment with opioids. The purpose of this study was to investigate the occurrence of endocrine dysfunction in chronic pain patients on long-term opioid treatment. A study group of 39 chronic pain patients treated with strong oral opioids for more than 1 year was compared with a control group of 20 chronic pain patients without opioid treatment. Basic levels of prolactin and function of the hypothalamic-pituitary-thyroid-, hypothalamic-pituitary-adrenal-axis, and hypothalamic-pituitary-growth-hormone - and hypothalamic-pituitary-gonadal-axis were measured. Quality-of-life and side effects were estimated with EORTC-QLQ-C30. In the opioid-treated group, the patients had signs of pituitary dysfunction affecting all axes. Significant differences were shown in hypofunction of the hypothalamic-pituitary-gonadal -axis, hyperfunction of the hypothalamic-pituitary-adrenal -axis, and higher prolactin levels in the opioid-treated group, compared with the control group. The degree of pain was rated the same in both groups, but the opioid-treated group reported more side effects and lower quality of life. Long-term treatment of chronic pain with strong opioids causes side effects that can be attributed to hormonal abnormalities caused by opioid-induced inhibition of hypothalamic-pituitary function. Hormone substitution can be indicated to treat symptoms. Decreasing the opioid dose or stopping the opioid treatment can reverse endocrine dysfunction. This needs to be recognized by all practitioners treating chronic pain patients with opioids.

Oral morphine is suitable for the treatment of chronic non-cancer pain

Oral morphine is suitable for the treatment of chronic non-cancer pain