opioid therapy of chronic pain: evolving trends nociception other physical symptoms physical...
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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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
Chronic Non-Cancer Pain
Changing perspectives – Evolving consensus among pain specialists– Gradual diffusion to primary care
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
Pain Specialists
Current view embodied in consensus statements from:
APS and AAPM
ASAM
CPS
Others
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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?
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Positioning Opioid Therapy: Positioning Opioid Therapy: Trends over 20 yearsTrends over 20 years
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
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
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
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Critical Issues– Effectiveness
Opioid responsivenessDurability of response (tolerance?)Achieving optimal therapy
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
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 Treatment of Opioid Treatment of Chronic PainChronic Pain
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
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
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
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Achieving Optimal Therapy– Drug selection
– Individualization of the dose
– Treating side effects
– Managing the poorly responsive patient
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Critical outcomes– Pain relief
– Side effects
– Function--physical and psychosocial
– Drug-related behaviors
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Critical Issues– Safety
– Major organ toxicity and risk of side effects
– Addiction liability
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
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
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
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
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Addiction– Disease with pharmacologic,
genetic, and psychosocial elements
– Distinguished from tolerance, physical dependence, and pseudoaddiction
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Addiction– Fundamental features
• Loss of control• Compulsive use• Use despite harm
– Diagnosed by observation of aberrant drug-related behavior
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
Aberrant Drug-Related Behavior–Differential Dx
• Addiction• Pseudoaddiction• Other psychiatric disorders• Encephalopathy• Family disturbances• Criminal intent
Opioid Treatment of Opioid Treatment of Chronic PainChronic Pain
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
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