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Long-term use of opioids for complex chronic pain

https://doi.org/10.1016/j.berh.2013.09.011Get rights and content

Abstract

Increased opioid prescribing for back pain and other chronic musculoskeletal pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of opioids for chronic musculoskeletal pain remains unknown. Given the lack of large, long-term randomised trials, recent epidemiologic data suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels. Principles for achieving more selective and cautious use of opioids for chronic musculoskeletal pain are proposed.

Section snippets

Opioids and complex chronic pain

Opioids are naturally occurring or synthetic chemicals resembling morphine in pharmacological effects and include oxycodone, morphine, hydrocodone, methadone, hydromorphone, meperidine (or pethidiine), fentanyl and codeine. Opioids bind to receptors that are principally found in the central and peripheral nervous systems as well as the gastrointestinal tract. They are commonly used for the following:

  • (1)

    Time-limited pain management of medical procedures, dental procedures and acute injury and

Trends in opioid prescribing

The global consumption of strong opioids (in morphine equivalent units) increased more than 30-fold from 1980 to 2010 [11]. However, there are substantial differences in opioid consumption between countries. In 2010, countries with the highest per capita consumption of strong opioids included the United States, Canada, Switzerland, Germany, Austria, Denmark, Australia, the United Kingdom, New Zealand and other countries with highly developed market economies. Countries in Africa and Asia with

An epidemic of prescription-opioid abuse and overdose

As opioid prescribing for chronic pain has increased, levels of prescription opioid addiction and overdose have reached epidemic proportions. Addiction to prescription opioids is defined by: using more opioids than intended; hazardous use; persistent desire or unsuccessful efforts to cut down; social or interpersonal problems related to opioid use; opioid craving; and psychological and/or physical problems related to opioid use [21]. Tolerance and physiological dependence are not considered in

Why opioid dose matters

Risks associated with COT increase with opioid dose [38], [39], ∗[40], [41], [42]. Risks to the broader community rise with increased dose as well. Prescription opioids used non-medically are most often obtained from family or friends or from home medicine cabinets [43]. For this reason, the amount of opioid medication available for diversion in the community is affected by the prevalence of high-dose COT, as over 60% of all legally prescribed morphine equivalents are dispensed to COT patients

The risk stratification paradigm

With growing recognition of potential opioid-related harms, there has been increased emphasis on clinical evaluation of prescription opioid-abuse risk factors to inform patient selection and monitoring [4], [49]. An assumption underlying risk stratification is that accurate prediction of opioid abuse risks is possible. It has been claimed that abuse risks are low among patients who do not have a personal or family history of substance abuse and without significant psychological disorders [50],

Patient risk factors

Initial studies reported good-to-excellent prediction of aberrant opioid-use behaviours using various screeners [58], [59], [60], [61], [62]. These screeners assessed patient risk factors for opioid misuse including substance use-disorder history, family history of substance use disorder and significant psychological problems. However, a structured review by Chou et al. [63] of opioid misuse prediction concluded that, “only limited evidence exists to determine optimal methods for prediction and

Drug regimen risk factors

As opioid dose increases physiological dependence, making discontinuation more difficult, dose escalation may influence risks of opioid misuse and abuse. Cross-sectional studies have found that COT patients receiving high opioid dose more often have substance abuse indicators and are more likely to report concerns about their ability to control opioid use [44], [54], [66], [67], [68], [69]. Over 80% of COT patients on higher doses sustained higher dose opioid use 1 year later, with sustained

Data questioning COT effectiveness

Observational studies have found that patients using opioids, and those on higher dose regimens, have poorer functional status and lower quality of life than patients not using opioids or patients on low-dose regimens [73], [74], [75], [76], [77]. Cohort studies of patients on worker's compensation found that those using opioids are delayed in returning to work relative to patients not using opioids and patients receiving higher opioid doses are also delayed returning to work relative to

Research gaps

A recent US Food and Drug Administration (FDA)-sponsored conference concluded that lack of data on safety of opioids for long-term management of chronic pain constitutes a major gap in knowledge [97]. There is a spectrum of potential adverse outcomes that clinical studies or epidemiological research has found to be associated with opioid use [16], but these adverse outcomes related to opioids have received only limited research attention:

  • Respiratory depression – opioid overdose and breathing

Practice points

Given the uncertainty about the long-term effectiveness of COT and growing evidence that potential risks and harms are greater than initially believed, use of opioids for long-term management of chronic pain should be considered with caution commensurate with the potential risks. While we await better evidence regarding COT effectiveness, practical strategies for protecting patient safety should be implemented on a trial basis and the effects on patient outcomes evaluated by clinicians and by

Summary

Increased opioid prescribing for common chronic pain conditions has been accompanied by dramatic increases in prescription-opioid addiction and fatal overdose. Opioid-related risks appear to increase with dose. Although short-term randomised trials of opioids for chronic pain have found modest analgesic benefits (a one-third reduction in pain intensity on average), the long-term safety and effectiveness of COT for chronic musculoskeletal pain are unknown. Given the lack of adequate trials data,

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    Work on this book chapter was supported, in part, by the National Institutes of Aging grant R01 AG034181.

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