Opioid Therapy of Chronic Pain: Evolving Trends Nociception Other physical symptoms Physical impairments NeuropathicPsychological Social isolation mechanismsprocessesFamily

Opioid Therapy of Chronic Opioid Therapy of Chronic Pain: Evolving TrendsPain: Evolving Trends

Nociception

Other physical symptoms

Physical impairments

Neuropathic Psychological Social isolation

mechanisms processes Family distress

Role disruption

Other co-morbidities

Pain

Disability/Suffering

Approaches to the Patient with Approaches to the Patient with Chronic PainChronic Pain

– Pharmacological

– Rehabilitative

– Psychological

– Anesthesiologic

Primary Rx for pain etiology

Symptomatic therapies:

– Surgical

– Neurostimulatory

– CAM

– Lifestyle change

Treatment of the Patient with Treatment of the Patient with Chronic PainChronic Pain

Pharmacotherapy– Opioid analgesics

– Nonopioid analgesics

– Adjuvant analgesics

– Syndrome-specific drugs (e.g., headache)

Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years

Early Consensus (Sustained)

First-Line Therapy for:

– Severe acute pain

– Moderate-severe chronic cancer pain


Evolving Recognition of Undertreatment

Research findings in acute pain, cancer and AIDS pain, and pain at EOL:– Opioid use contrary to published guidelines– Worse than expected patient outcomes– Clinicians with limited knowledge about

opioids and negative attitudes


Evolving Recognition of Barriers • Patient-related factors

– stoicism, fear of addiction

• System factors– fragmented care, lack of reimbursement

• Clinician-related factors– Poor knowledge of pain management, opioid

pharmacology, and chemical dependency – Fear of regulatory oversight


Efforts to Redress Undertreatment– Guidelines and consensus statements from

professional societies– New standards (JCAHCO)– Educational initiatives supported by academic

programs, professional societies and organizations, and industry


Chronic Non-Cancer Pain

Changing perspectives – Evolving consensus among pain specialists– Gradual diffusion to primary care


Pain Specialists

Early negative view influenced by experience of chronic pain programs:

• Opioids associated with poor function• Opioids associated with substance use

disorders and other psychiatric disorders• Opioids associated with poor outcome


Pain Specialists

Increasing use of long-term opioid therapy– Slowly growing evidence base

– More sophisticated pharmacologic understanding

– Reassurance from regulators and law enforcement

– Influence of broad movement to improve acute pain and cancer pain treatment

– Pressure from the media

– Influence of industry


Pain Specialists

Current view embodied in consensus statements from:

APS and AAPM

ASAM

CPS

Others


Pain specialists believe that opioids are significantly underused for chronic non-cancer pain • Recognition of barriers as illegitimate• Recognition of biases in published reports from

multidisciplinary pain programs • Positive reports in the literature and personal

experiences with patients


Pain specialists support the use of opioid therapy by primary care MDs• Recognition of barriers as illegitimate • Belief that treatment principles are simple• Knowledge of pain epidemiology• Feeling overwhelmed• Influence of advocates, media, and industry


Pain Specialists

Recent acknowledgement of concerns:• Many specialists have inadequate knowledge of

addiction medicine principles, which are essential to safe and effective treatment

• Generalists are adopting the therapy without adequate knowledge of pain management principles, opioid pharmacology, and addiction medicine principles


Pain Specialists

Recent acknowledgement of concerns:• Tacit reluctance on the part of supporters--

specialists, media, patient advocates, and industry--to discuss legitimate risks associated with opioid toxicity and abuse/addiction liability


Evolving Consensus• Still considered first-line for patients with severe

acute pain, and moderate to severe pain related to cancer or AIDS, or other life-threatening illness


Evolving Consensus• Consider for all patients with moderate to severe

non-cancer pain, but weigh the influences:• What is conventional practice?• Are opioids likely to work well? • Are there reasonable alternatives?• Will the risk of side effects be relatively high?• Are drug-related behaviors likely to be

responsible?


Evolving Consensus

Safe and effective therapy requires:• Knowledge and skills sufficient to assess pain

and relevant co-morbidities• Knowledge of conventional pain treatments

sufficient to appropriately position opioid therapy among others

• Knowledge of opioid pharmacotherapy


Evolving Consensus:

Safe and effective therapy requires:• Knowledge and skills in addiction medicine

sufficient to judge risks, monitor treatment, and handle problems

• Commitment to documentation and infrastructure


Evolving Consensus

Safe and effective therapy requires:• Pain specialists as consultants educated in both

pain management and principles of addiction medicine

Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain

Critical Issues for Ongoing Review– Perceived risk of sanctions

– Establishing effectiveness

– Understanding safety considerations


Critical Issues– Perceived risk of sanctions

• Survey of >1300 NYS physicians (1998) showed that >50% moderately to very concerned about regulatory scrutiny and 25-50% admit changing practice because of concern


Critical Issues– Effectiveness

Opioid responsivenessDurability of response (tolerance?)Achieving optimal therapy


Opioid Responsiveness– Many thousands of patients reported in

surveys of cancer pain--70-90% efficacy

– Numerous surveys of patients with non-cancer pain--25-70% efficacy

– Small number of relevant RCT’s


Opioid Responsiveness– Conclusion:

– Opioid therapy probably can be effective for any type of pain syndrome

• But data are limited • Responsiveness varies across individuals and

subpopulations• Responsiveness cannot be assessed unless therapy

is optimized by individualization of the dose


Durability of Response – Conclusions:

– Tolerance is complex– Most patients stabilize at a dose for a

prolonged period– Fear of tolerance is greater problem than its

effect on therapy


Achieving Optimal Therapy– Drug selection

– Individualization of the dose

– Treating side effects

– Managing the poorly responsive patient


Critical outcomes– Pain relief

– Side effects

– Function--physical and psychosocial

– Drug-related behaviors


Critical Issues– Safety

– Major organ toxicity and risk of side effects

– Addiction liability


Toxicity and Side Effects– Conclusions

– No major organ toxicity– Persistent side effects in some, but most

achieve a favorable balance between analgesia and side effects

– Studies suggest that most normalize cognitive function and driving usually not impaired


Addiction Liability• Relevant definitions evolving

(APS/AAPM/ASAM)

• Relevance of studies limited• Acute Pain: Very unlikely• Cancer Pain: Very unlikely• Chronic Non-Cancer Pain: Mixed results


Addiction– Disease with pharmacologic,

genetic, and psychosocial elements

– Distinguished from tolerance, physical dependence, and pseudoaddiction


Addiction– Fundamental features

• Loss of control• Compulsive use• Use despite harm

– Diagnosed by observation of aberrant drug-related behavior


Aberrant Drug-Related Behavior–Differential Dx

• Addiction• Pseudoaddiction• Other psychiatric disorders• Encephalopathy• Family disturbances• Criminal intent


Aberrant Drug-Related Behavior• Monitor• Diagnose the disorder• Manage the behavior• Treat the disorder

Opioid Therapy: ConclusionsOpioid Therapy: Conclusions

• An approach with extraordinary promise and substantial risks

• An approach with clear obligations on prescribers – Assessment and reassessment– Skillful drug administration– Knowledge of addiction medicine principles– Documentation and communication

Documents

Opioid Therapy of Chronic Pain: Evolving Trends Nociception Other physical symptoms Physical impairments NeuropathicPsychological Social isolation mechanismsprocessesFamily