Opioids for chronic pain treatment

Efficacy: Opioids can be highly effective for managing certain types of chronic pain, especially when other treatments have failed. They are typically reserved for severe pain, such as cancer-related pain or pain following major surgery.

Risks and Side Effects: Opioids come with significant risks and side effects. These can include physical dependence, tolerance (requiring higher doses for the same effect), withdrawal symptoms, constipation, drowsiness, and the potential for overdose, which can be fatal.

Alternative Treatments: Many alternative treatments are available for chronic pain, depending on the underlying cause. These may include physical therapy, non-opioid medications, lifestyle modifications, cognitive-behavioral therapy, and interventional procedures like nerve blocks.

Opioid Prescribing Guidelines: To address the opioid epidemic, many countries, including the United States, have established stricter guidelines for opioid prescribing. These guidelines aim to limit the use of opioids for chronic pain and promote safer prescribing practices.

Patient Education: Patients and healthcare providers should engage in open and honest discussions about the benefits and risks of using opioids for chronic pain management. It's essential for patients to be informed about the potential side effects and risks, as well as to have a clear understanding of the treatment plan and goals.

Monitoring and Follow-Up: Opioid therapy for chronic pain should be closely monitored by a healthcare provider. Regular check-ups are important to assess the effectiveness of the treatment, monitor for any signs of misuse or dependence, and adjust the treatment plan as necessary.

Risk Assessment: Healthcare providers should conduct a thorough assessment of each patient's risk factors for opioid misuse, addiction, and overdose before prescribing opioids for chronic pain. This may involve screening tools and discussions about the patient's medical history and substance use history.

Multi-Disciplinary Approach: Chronic pain management often benefits from a multidisciplinary approach, which can include a combination of therapies, treatments, and support from different healthcare professionals, such as pain specialists, physical therapists, and mental health professionals.

It's important to note that the use of opioids for chronic pain is a complex issue that should be approached with caution and care. In recent years, there has been a growing emphasis on reducing opioid prescriptions and promoting alternative treatments due to the opioid epidemic and the associated risks. Patients with chronic pain should work closely with their healthcare providers to develop a personalized pain management plan that considers their specific needs, circumstances, and the potential benefits and risks of opioid therapy.

The risk of addiction associated with the use of opioids for chronic pain treatment is a significant concern and a topic of extensive research and clinical consideration. It's crucial to understand that while opioids can be effective at managing pain, they also carry a substantial risk of addiction, especially when used for an extended period. Here are some key points to consider regarding the risk of addiction associated with opioids for chronic pain treatment:

Dependence vs. Addiction: It's important to differentiate between physical dependence and addiction. Physical dependence occurs when the body becomes accustomed to the presence of the opioid, leading to withdrawal symptoms when the medication is discontinued. Addiction, on the other hand, involves compulsive drug use, cravings, and a loss of control over drug-seeking behavior.

Risk Factors: Several risk factors can increase the likelihood of developing an opioid addiction, including a personal or family history of substance use disorders, a history of mental health issues, and a history of previous substance misuse.

Duration of Use: The longer opioids are used, the greater the risk of developing addiction. While they may be appropriate for short-term pain management, using them for an extended period increases the likelihood of dependence and addiction.

Dosing and Tolerance: Opioid tolerance can develop over time, leading individuals to require higher doses to achieve the same level of pain relief. This can contribute to the risk of addiction, as increasing doses can heighten the potential for dependence.

Prescribing Practices: Prescribing practices play a crucial role in the risk of opioid addiction. Healthcare providers should carefully assess patients for their suitability for opioid therapy, prescribe the lowest effective dose, and monitor patients for signs of misuse or addiction.

Alternative Treatments: For chronic pain management, there are often alternative treatments available that carry a lower risk of addiction, such as non-opioid medications, physical therapy, acupuncture, and behavioral interventions. These options should be considered before resorting to opioids.

Opioid Epidemic: The opioid epidemic in many countries, including the United States, has raised awareness of the risks associated with opioid use. Stricter guidelines and regulations have been put in place to reduce opioid prescribing, especially for chronic pain.

Education and Monitoring: Patients and healthcare providers should engage in open and honest communication about the risks associated with opioids. Regular monitoring and evaluation of the patient's condition and pain management plan are essential to identify any early signs of misuse or addiction.

Treatment for Addiction: If addiction does develop, it's crucial to provide access to appropriate treatment and support. Medications like buprenorphine and methadone, along with counseling and behavioral therapies, can be effective in managing opioid addiction.

In summary, while opioids can be effective in managing chronic pain, their potential for addiction is a substantial concern. The risk of addiction is influenced by various factors, including the duration of use, dosing, personal history, and prescribing practices. It's essential for both patients and healthcare providers to be informed about these risks and to carefully weigh the benefits and potential harms of using opioids for chronic pain treatment. In many cases, alternative, less addictive treatments may be more suitable for managing chronic pain.

A qualitative descriptive study used a content analysis of semistructured interviews. Themes were identified through a reflective, iterative coding process. Consolidated criteria for reporting qualitative research guidelines were followed.

Setting: West Virginia.

Participants: Twenty people who used opioids to treat a CP condition, 10 pharmacists, 10 primary care providers, and 10 specialists.

Intervention: Semistructured interviews.

Main outcome measure: To better understand the impact of restrictive prescribing measures on people who used opioids for CP.

Results: Patients initiated opioids for acute, painful conditions and described how long-term use led to physical dependence and, for some, opioid use disorder. Restrictive opioid prescribing laws led to care interruptions and decreased access and availability of prescribed opioid pain medication, driving some patients to seek illicit drugs. Economic considerations influenced drug use as the price of purchasing prescription opioids on the street went up, making heroin a cheaper alternative. Patients who transitioned to buprenorphine/naloxone as a treatment for pain or opioid use disorder viewed it as a positive change and a “life saver.”

Conclusions: Opioid use for CP is complex and multifaceted. The continuum of pain and opioid use disorder can begin with a prescription for acute pain and continue for the treatment of CP. Patients described how continued opioid use was not to “get high” but for pain control to improve their quality of life, continue to work, and be productive. For those who experience physical dependence on opioids, access to treatment is vital to recovery and pain management.

Key message: Without individualized managed care, people confronted with a sudden interruption in prescription opioids may turn to illicit drugs to mitigate symptoms of opioid withdrawal and physical dependence 1).

In conclusion, the study offers valuable insights into the challenges faced by individuals using opioids for chronic pain and the unintended consequences of restrictive prescribing measures. It emphasizes the importance of tailored, comprehensive care and access to appropriate treatments, taking into account the complex interplay of chronic pain, opioid use, and opioid use disorder. The findings have relevance not only in West Virginia but also in regions grappling with similar issues related to opioids and chronic pain management.

There is no evidence to support the use of epidural injections of steroids, local anesthetics and/or opioids for low back pain without radiculopathy

Opioid may be required for severe pain, usually severe radicular pain. For non-specific back pain, there was no earlier return to full activity than with Nonsteroidal anti-inflammatory drug or APAP 2) Opioids should not be used > 2–3 weeks, at which time NSAIDs should be instituted unless contraindicated

see Opioid for low back pain.

Opioids remain a mainstay in the treatment of acute and chronic pain, despite numerous and potentially dangerous side effects. There is a great unmet medical need for alternative treatments for patients suffering from pain that do not result in addiction or adverse side effects.

Since 2016, 35 of 50 USA states have passed opioid-limiting laws.

Implementation of mandatory opioid prescribing limits effectively decreased 30-day postoperative opioid utilization following ACDF without a rebound increase in prescription refills, ED visits, unplanned hospital readmissions, or reoperations for pain 3).

Intrathecal (IT) opioid pumps are one therapeutic cornerstone of refractory non-malignant pain syndromes. The aim of this study was to evaluate efficacy, surgical and pharmacological complications of IT pumps beyond a time span of 10 years.

In this retrospective single-center cohort study, 27 patients (14 female, 13 male, age 64.0 ± 8.9 (median, 1 SD) yrs) were identified. Pain intensity using the numerical rating scale (NRS), pain and IT pump characteristics, and complications were analyzed. The German Pain Questionaire was used to investigate the physical and mental health status.

Overall time of IT therapy from first implantation to last follow-up was 20.4 ± 6.0 yrs. Time to implantation of the second pump (n=18) was 10.0 ± 5.3 yrs, between the second and third pump (n=6) 6.5 ± 2.7 yrs, and two patients received their 4th pump six years later. Before implantation, NRS was 9.0 ± 0.9, one year after implantation 7.0 ± 1.8 and 4.0 ± 2.3 at the last follow-up. IT drug dose remained stable after 3 years. Opioid intoxications occurred in three patients (10%). One patient (3%) underwent revision surgery due to a catheter infection. Drug side effects occurred in 4 patients (14%). Our patient group has pain-related restrictions in physical activities with menial impact regarding mental and emotional stress.

Even after a time span of over 15 years and several exchanges of pump systems, pain intensity is still reduced. After 3 years, IT drug dose remained unchanged with low side-effects and complication rates 4).

Sedney CL, Dekeseredy P, Davis M, Haggerty T. A qualitative study of chronic pain and opioid use: The impact of restrictive prescribing. J Opioid Manag. 2023 Special-Issue;19(7):95-102. doi: 10.5055/jom.2023.0803. PMID: 37879664.
Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults. Clinical Practice Guideline No.14. AHCPR Publication No. 95-0642. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services; 1994
Reid DBC, Patel SA, Shah KN, Shapiro BH, Ruddell JH, Akelman E, Palumbo MA, Daniels AH. Opioid-Limiting Legislation Associated with Decreased 30-Day Opioid Utilization Following Anterior Cervical Decompression and Fusion. Spine J. 2019 Sep 2. pii: S1529-9430(19)30960-X. doi: 10.1016/j.spinee.2019.08.014. [Epub ahead of print] PubMed PMID: 31487559.
Sommer B, Karageorgos N, AlSharif M, Stubbe H, Hans FJ. Long-term outcome and adverse events of intrathecal opiod therapy for non-malignant pain syndrome. Pain Pract. 2019 Jul 10. doi: 10.1111/papr.12818. [Epub ahead of print] PubMed PMID: 31291509.
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