Monte H. Moore, MD Idaho Physical Medicine and Rehabilitation Meridian, ID
Chronic pain brief review Opiates important things to know Factors in determining whether to use an opiate What to watch for if you decide to prescribe What to do if your patient fails to comply
Pain is the most common reason for physician consultation in the United States. It is a major symptom in many medical conditions, and can significantly interfere with a person's quality of life and general functioning.
sometimes pain persists despite removal of the stimulus and apparent healing of the body; and sometimes pain arises in the absence of any detectable stimulus, damage or disease.
3 months 6 months Pain that extends beyond the expected period of healing
Fear of injury Isolation Loss of work, $ and love, selfesteem Anxiety Depletion
Somatic or nociceptive: arthritis fracture post surgical acute musculoskeletal injuries
Central neuropathic: stroke fibromyalgia chronic pain with a strong psychological component
Peripheral neuropathic: compression neuropathy radiculopathy polyneuropathy postherpetic neuralgia phantom limb pain post amputation
May be more effective than other alternatives Low toxicity to gut, kidneys Intolerances to other drugs
Abuse potential Health risk, including death Risk of diversion Controversy regarding long term efficacy Irritating issues with patients who misuse opiates
5% of Americans over age 12 use prescription pain relievers for nonmedical purposes 70% obtain the medication from a friend or relative
Jefferson School of Population Health 2009 938,586 patients: 75% unlikely to be taking medications as prescribed 38% no detectable level of the drug prescribed 29% had a non-prescribed drug 27% had a level higher than expected 15% had a level lower than expected
Clinicians who prescribe opioids to treat chronic pain are often caught between their professional obligation to relieve suffering and their desire to avoid contributing to the non-medical consumption of controlled substances
Dependence Abstinence syndrome Tolerance Down regulation of opiate receptors Abuse Craving or Compulsion. Continued use despite adverse consequences Loss of Control
Behaviors that mimic addiction. May present in a patient with or without a history of or risk factors for drug abuse or true addiction. Often occurs in the setting of acute pain that is overlaid on a chronic pain condition. Climate of distrust and conflict between the patient and the care team related to the use of opioids for pain.
Pseudoaddiction
Neuropathic pain Significant comorbid psychopathology Long prior use of opiates (tolerance to opiates) Smoker Family history of chemical abuse
Function and quality of life will improve with a trial of increased opiates. Careful observation and knowledge of patient required
Nociceptive pain such as arthritis Psychologically stable Older patient No prior history of chemical abuse Non-smoker Negative family history of chemical abuse
Cognitive Hypotestosteronism in males and females Central sleep apnea Opioid-induced hyperalgesia
Sedation/impaired cognitive function Frequently in combination with other sedatives Patient usually unaware Family may be aware but may not see the connection or may not say anything Improves with reduction in dosage
Hypotestosteronism in males and females May be due to pituitary depletion from chronic pain Opioid suppression of GnRH in the hypothalamus Direct suppresion of testosterone production in the adrenal or gonads
Symptoms of low testosterone Lack of energy Loss of libido Depression Poor healing Diminished Opioid effects Apathy, weakness Suspect in any patient taking long term opiates Dose-related
Hypotestosteronism in males and females Reduces opioid receptor binding Treatable
Central sleep apnea Suppression of central breathing mechanism Fatigue, insomnia Reduced cognitive function Health risks of sleep apnea
Opioid-induced hyperalgesia Opioid neurotoxicity Enhanced sensitivity to painful stimuli Opioids may worsen initial pain & sensitivity to other sources of pain Often improves with opiate reduction
1. Evaluation of patient s expectations Document baseline function: Driving Cooking/cleaning Working Sleeping What does the patient want to be able to do? Are Goals realistic?
2. Is the pain likely to respond to low dose opiates? Somatic Neuropathic 3. Has there been a reasonable trial with non-opiate medications?
Nociceptive pain NSAIDs Tylenol Tramadol
Neuropathic pain Anticonvulsants Gabapentin (Neurontin) Pregabalin (Lyrica) Tiagabine (Gabitril) SNRI Venlafaxine (Effexor) Duloxetine (Cymbalta Milnacipran (Savella) Desvenlafaxine (Pristiq)
Neuropathic pain Muscle relaxers Lioresal (Baclofen) Deafferentation pain such as neuropathy or phantom limb pain Tizanidine (Zanaflex) Good for insomnia relating to neuropathic pain Tramadol Acts centrally at the opiate receptor and has potential for abuse, although less than other opiates May be effective for neuropathic pain
Neuropathic pain Tapendadol (Nucynta) Centrally acting analgesic u receptor agonist Norepinephrine uptake inhibitor Similar to hydrocodone in it s ability to relieve pain Electrical Stimulation
4. What other factors affect the pain and is there a way to address them? Deconditioning Behavioral reinforcers Depression and anxiety Smoking Testosterone Sleep disorders
physical therapy exercise injections surgery
5. Can you trust your patient? Your experience with patient Board of Pharmacy - http://ipmp.bop.idaho.gov Drug screens Other illegal activity : https://www.idcourts.us/r epository/start.do
***OPIATE RISK TOOL*** FAMILY HISTORY: - alcohol abuse M3/F1 - illegal drug use M3/F1 - prescription drug abuse M4/F4
PERSONAL HISTORY: - alcohol abuse M3/F3 - illegal drug use M4/F4 - presciption drug abuse M5/F5
MENTAL HEALTH: - Dx of ADD, OCD, bipolar, schizophrenia M2/F2 - Dx of depression M1/F1
OTHER - age 16-45 M1F1 - history of preadolescent sexual abuse M0/F3 TOTAL: SCORING: 0-3 low risk 4-7 moderate risk 8 or greater high risk
6. What are the medical risks to your patient if opiates are used? Drug interactions (other sedating medications) CNS dysfunction Sleep disturbance Liver disease Hypotestosteronism Risk of abuse and diversion
Set up clear expectations chronic pain agreement Continue to utilize non-opiates, lifestyle change, and other reasonable interventions to every extent possible Watch for drug interactions Evaluate whether the opiate is achieving the initial goals Monitor for compliance Monitor for side effects and interactions
Treat concurrent mental health disorders Be sensitive to medication costs Check for low testosterone and sleep apnea, especially if taking high doses Educate, educate, educate why you don t want to ask me to increase your dose today
Face to face conversation explaining why you aren t comfortable prescribing Refer rather than abandoning - consider referral for addiction evaluation Consider pain specialist
The challenge is to curtail the abuse and diversion of prescription opioids while ensuring their availability for patients who benefit from their use. Lynn R. Webster
The obligations to battle pain and addiction are not mutually exclusive, they are mutually inextricable Lynn R. Webster