Download Pain - Full Circle Center for Integrative Medicine

Opioids in Chronic Pain
Management
o
o
o
o
Benefits and Risks
Side effects: constipation, sleep disruption,
altered mental status, itching, nausea,
respiratory depression
Addiction vs. Dependence
Assessing whether medication improves
quality of life and participation in life or
diminishes them
Benefits of Opioids for Pain
o
o
Opioids “take the edge off pain” or “make it
easier to manage it”
Opioids do not eliminate pain, in
therapeutic doses
Goals of Opioid Use
o
In Cancer Pain: Improved Quality of Life
o Relief of suffering, even if there is sedation, etc.
o
In Nonmalignant Pain: Improved Function
Timing
o
Short-acting/Rescue medications: codeine,
hydrocodone, oxycodone, morphine
Drug level
time
Problems with Short-acting Medications
Drug level
Loaded
In pain
Time
Long-acting narcotics:
Drug level
Time
•
•
•
•
Fentanyl patches (Duragesic)
Methadone
MS Contin
OxyContin
o Need to be dosed on a schedule, not prn
Side Effects of Opioids
o
o
o
o
o
o
o
o
o
Nausea and Vomiting
Constipation
Sedation- sleepiness
Respiratory depression
Urinary retention (difficulty peeing)
Dysphoria – depression
Gonadal atrophy
Myoclonus, muscular rigidity
Increase in Pain Sensitivity
Opioid-induced Hyperalgesia
o
o
Animal studies show that repeated opioid
administration. . . can lead to a progressive
and lasting reduction of baseline
nociceptive thresholds, resulting in an
increase in pain sensitivity.
The decreased baseline nociceptive
thresholds lasted as long as 5 days after the
cessation of four fentanyl bolus injections
Opioid-induced Hyperalgesia
Six chronic low back pain patients were assessed
for both opioid tolerance and opioid-induced
hyperalgesia using quantitative sensory testing
(cold and heat) before and after the institution of
oral morphine therapy.
o Preliminary results showed hyperalgesia and
tolerance with cold but no hyperalgesia with heat
or analgesic tolerance to heat pain.
o
o
Chu L.F., Clark D.J., Angst M.S.: Opioid tolerance and hyperalgesia in chronic pain patients after one month of oral
morphine therapy: a preliminary prospective study. J Pain 7. (1): 43-48.2006
Opioid-induced Hyperalgesia
o
Patients treated intraoperatively with
remifentanil reported more postoperative
pain than the matched nonopioid controls
o
Vinik H.R., Igor K.: Rapid development of tolerance to analgesia during remifentanil infusion in
humans. Anesth Analg 86. 307-311.1998;
Crawford M.W., Hickey C., Zaarour C., et al: Development of acute opioid tolerance during infusion
of remifentanil for pediatric scoliosis surgery. Anesth Analg 102. (6): 1662-1667.2006;
Guignard B., Bossard A.E., Coste C., et al: Acute opioid tolerance: intraoperative remifentanil
increases postoperative pain and morphine requiremnt. Anesthesiology 93. (2): 409-417.2000;
o
Opioid-induced Hyperalgesia
o
A number of case reports document
decreases in pain with stopping opioids
o
Wilson G.R., Reisfield G.M.: Morphine hyperalgesia: a case report. Am J Hosp Palliat Care 20. (6):
459-461.2003
Mercadante S., Ferrera P., Villari P., et al: Hyperalgesia: an emerging iatrogenic syndrome. J Pain
Symptom Manage 26. (2): 769-775.2003;
Heger S., Maier C., Otter K., et al: Morphine induced allodynia in a child with brain
tumour. BMJ 319. (7210): 627-629.1999;
Sjogren P., Jensen N.H., Jensen T.S.: Disappearance of morphine-induced hyperalgesia after
discontinuing or substituting morphine with opioid agonists. Pain 59. 313-316.1994;
o
o
o
o
Mechanism may be NMDA receptor-mediated
central sensitization
Some Definitions
Tolerance
is a state resulting from
regular use of opioid(s) in which an increased
dose of the substance is needed to produce
the desired effect.
o Physical dependence
is a physiologic
state of adaptation to a specific opioid(s)
characterized by the emergence of a
withdrawal syndrome during abstinence,
which may be relieved in total or in part by readministration of the substance.
o
Definitions
o
o
Withdrawal syndrome is a specific
constellation of signs and symptoms
due to the abrupt cessation of, or
reduction in, a regularly administered
dose of opioid(s).
Pseudoaddiction – Medication-seeking
behaviors that arise as a result of pain
being poorly controlled
Definitions
o
Addiction is a disease process involving use
of opioid(s) wherein there is a loss of control,
compulsive use, and continued use despite
adverse social, physical, psychological,
occupational, or economic consequences.
o
Substance abuse
is the use of any
substance(s) for non-therapeutic purposes; or
use of medication for purposes other than
those for which it is prescribed.
Patients
vs.
Control of medication
o Medications increase
quality of life
o Medications are
decreased if side effects
occur
o Concerned about
medical problem
o Follow the contract
o Medications left over
o
Addicts
Med use not controlled
o Medications decrease
quality of life
o Medications continued
in the face of side
effects
o Lack of concern about
medical problems
o Ignore the contract
o Never have medication
left; often have stories
about drug losses and
shortages
o
Addiction in Patients with
Chronic Pain
(1) Intense desire for the drug and overwhelming concern
about its continued availability (psychological
dependence)
o (2) Evidence of compulsive drug use
o
o
o
o
o
unsanctioned dose escalation
continued dosing despite significant side effects
Use of drug to treat symptoms not targeted by therapy
Unapproved use during period of no symptoms
Or – see next slide
Addiction in Patients with
Chronic Pain
o
(3) Evidence of one or more of a group of
associated behaviors
o manipulation of the treating physician or medical
system for the purposes of obtaining additional drug
(altering prescriptions, for example)
o Acquisition of drugs from other medical sources or
from a nonmedical source
o Drug hoarding or sales
o Unapproved use of other drugs (particularly alcohol or
other sedatives/hypnotics) during opioid therapy
Questions to Ask:
o
o
o
o
o
Is the person’s day centered around taking medication?
Does the person take pain medication only on occasion,
perhaps three or four pills per week?
Have there been any other chemical (alcohol or drug)
abuse problems in the person’s life?
Does the person in pain spend most of the day resting,
avoiding activity, or feeling depressed?
Is the pain person able to function (work, household
chores, and play) with pain medication in a way that is
clearly better than without?
Signs Someone Is Being Harmed More
Than Helped by Pain Medication
o
o
o
o
o
o
o
o
Sleeping too much or having days and nights
confused
Decrease in appetite
Inability to concentrate or short attention span
Mood swings (especially irritability)
Lack of involvement with others
Difficulty functioning due to drug effects
Use of drugs to regress rather than to facilitate
involvement in life
Lack of attention to appearance and hygiene
Addiction Issues with Non-Opioids
o
Many of the same questions apply when
looking at use of
o Muscle Relaxants
o Cannabis
o Other adjunctive medications –
 Anticonvulsants
 Etc.
Adjunctive Medications
o
o
o
o
o
Topical – lidocaine, capsaicin,
antiinflammatories, other
Antidepressants
Anticonvulsants
Antiarrhythmic drugs
Ultram
Antidepressants for Pain
o
o
Work by affecting neurotransmitters
Do not only work for treating pain by
improving depression.
o Work as well in non-depressed people as in
people with depression
o Effectiveness for pain does not correlate with
effectiveness for depression
o
Do not work for all types of pain.
Stopping or Tapering Opioids
o
Withdrawal Symptoms
o
o
o
o
o
o
o
Anxiety/Restlessness
Sweating
Insomnia
Diarrhea
Nausea, vomiting
Yawning, rhinorrhea (runny nose)
Transient increase in pain
Treatment of Withdrawal
o
Each of the symptoms of withdrawal can be
treated, and herbal support is also available for
opioid withdrawal
o Passionflower
o Clonidine
o Lomotil
o Hydroxyzine
o Trazodone
o Etc.