A Brief Synopsis of AFP's Rational Use of Opioids for Management of Chronic Nonterminal Pain"

Rational Use of Opioids for Management of Chronic Nonterminal Pain
DANIEL BERLAND, MD, and PHILLIP RODGERS, MD, University of Michigan Medical School, Ann Arbor, Michigan
Am Fam Physician. 2012 Aug 1;86(3):252-258.
http://www.aafp.org/afp/2012/0801/p252.pdf


     Pain management is a large part of why people see their doctors. Most patients assume that all pain needs to be treated with opioids  Opioids are well know to be highly addictive and overused. It is now even more popular than illicit drug use. Overuse of opioids can cause opioid  induced hyperalgesia, where an increase in opioid use causes a paradoxical increase in pain. 
     Acute pain is different from chronic pain. Acute pain can be relieved with opioids while tissue recovery takes place. Chronic pain is from "complex CNS signalling" involved with biopsychosocial factors that will not resolve acute pain therapy. Opioid treatment should not be used in those with chronic central or visceral pain. These factors can be addressed with modalities such as physical therapy, massage, heat, steroid injections, topical lidocaine, or electric stimulations. Diet, exercise, and proper sleep can make a big impact on chronic pain as well. SSRI's are effective for neuropathic pain.  TCA's can be used if the neuropathy is concomitant with headaches, depression, panic disorder or tobacco addiction. Comorbid psychiatric illnesses such as anxiety, depression, or PTSD, should be treated accordingly.  After all these factors are dealt with, then opioids may be considered.
     The patient should have a comprehensive evaluation and their risk of potential abuse determined before beginning them on a trial basis.  The patient should understand that the goal of opioid therapy is to improve function, not decrease pain, per se. A written agreement should be set up instructing the patient not to be treated by multiple physicians or go to multiple pharmacies for the opioids.  Refill policies, "loosing prescriptions , regular drug testing, regular follow ups, and asking for refills early should all be incorporated into this agreement. 
     Morphine is a good first-line therapy because it is long acting, inexpensive, and reliable. Side effects include nausea, pruritus, constipation and drowsiness. Patients with a morphine allergy can be prescribed oxycodone, although it has a higher potential for abuse. Fentanyl patches or buprenorphine are an expensive alternative. Methadone may be an option because of its long action and lower tolerance rates, but it can cause arrhythmias such as prolonged QT syndrome. Multiple opioids should not be used simultaneously and the meds should be consolidated with a narcotic conversion calculator. Total opioid doses over 100 mg of a morphine equivalent is associated with an increased risk of overdose.
     In acute pain, the idea of giving a short acting medication PRN for "breakthrough pain" is common. It has been show that this concept has not improved outcomes and has only increased the risk of misuse and tolerance. Long acting, sustained-release preparations are preferred. 
     Once the therapy has run it course or has been deemed ineffective or unsafe, the medication should be tapered. A slow taper can be done by decreasing the dose by 10% every one to four weeks, and then by 5% for the last 20% of the original dose. Rapid tapering can be done by decreasing the dose by 25% every three to seven days. Therapy should not be continued for fear of withdrawal symptom because they are usually non life-threatening.  WIthdrawal can be tempered with clonidine or tramadol.