Opioids in Chronic Pain Management
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Opioids in Chronic Pain Opioids in Chronic Pain Management Management o Benefits and Risks o Side effects: constipation, sleep disruption, altered mental status, itching, nausea, respiratory depression o Addiction vs. Dependence o Assessing whether medication improves quality of life and participation in life or diminishes them
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Opioids in Chronic Pain Management. 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. - PowerPoint PPT Presentation
Transcript of Opioids in Chronic Pain Management
Opioids in Chronic Pain Opioids in Chronic Pain ManagementManagement
o Benefits and Riskso Side effects: constipation, sleep disruption,
altered mental status, itching, nausea, respiratory depression
o Addiction vs. Dependenceo Assessing whether medication improves
quality of life and participation in life or diminishes them
Benefits of Opioids for PainBenefits of Opioids for Pain
o Opioids “take the edge off pain” or “make it easier to manage it”
o Opioids do not eliminate pain, in therapeutic doses
Goals of Opioid UseGoals of Opioid Use
o In Cancer Pain: Improved Quality of Lifeo Relief of suffering, even if there is sedation, etc.
o In Nonmalignant Pain: Improved Function
TimingTiming
o Short-acting/Rescue medications: codeine, hydrocodone, oxycodone, morphine
Drug level
time
Problems with Short-acting MedicationsProblems with Short-acting Medications
Drug level Loaded
In pain
Time
Long-acting narcotics:Long-acting narcotics:
Drug level
Time
• Fentanyl patches (Duragesic)
• Methadone
• MS Contin
• OxyContino Need to be dosed on a schedule, not prn
Side Effects of OpioidsSide Effects of Opioidso Nausea and Vomitingo Constipationo Sedation- sleepinesso Respiratory depressiono Urinary retention (difficulty peeing)o Dysphoria – depressiono Gonadal atrophyo Myoclonus, muscular rigidityo Increase in Pain Sensitivity
Opioid-induced HyperalgesiaOpioid-induced Hyperalgesia
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.
o The decreased baseline nociceptive thresholds lasted as long as 5 days after the cessation of four fentanyl bolus injections
Opioid-induced HyperalgesiaOpioid-induced Hyperalgesia
o 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 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 HyperalgesiaOpioid-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;
o 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;
Opioid-induced HyperalgesiaOpioid-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;
o Heger S., Maier C., Otter K., et al: Morphine induced allodynia in a child with brain tumour. BMJ 319. (7210): 627-629.1999;
o 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 Mechanism may be NMDA receptor-mediated central sensitization
o
Some DefinitionsSome Definitions
o 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 re-administration of the substance.
DefinitionsDefinitions
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).
o Pseudoaddiction – Medication-seeking behaviors that arise as a result of pain being poorly controlled
DefinitionsDefinitionso 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. AddictsPatients vs. Addicts
o Control of medicationo Medications increase
quality of lifeo Medications are
decreased if side effects occur
o Concerned about medical problem
o Follow the contracto Medications left over
o Med use not controlledo Medications decrease
quality of lifeo Medications continued in
the face of side effectso Lack of concern about
medical problemso Ignore the contracto Never have medication
left; often have stories about drug losses and shortages
Addiction in Patients with Addiction in Patients with Chronic PainChronic Pain
o (1) Intense desire for the drug and overwhelming concern about its continued availability (psychological dependence)
o (2) Evidence of compulsive drug use o unsanctioned dose escalationo continued dosing despite significant side effectso Use of drug to treat symptoms not targeted by therapyo Unapproved use during period of no symptoms
Or – see next slide
Addiction in Patients with Addiction in Patients with Chronic PainChronic Pain
o (3) Evidence of one or more of a group of associated behaviorso 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 saleso Unapproved use of other drugs (particularly alcohol or
other sedatives/hypnotics) during opioid therapy
Questions to Ask:Questions to Ask:
o Is the person’s day centered around taking medication?o Does the person take pain medication only on occasion,
perhaps three or four pills per week? o Have there been any other chemical (alcohol or drug)
abuse problems in the person’s life? o Does the person in pain spend most of the day resting,
avoiding activity, or feeling depressed? o 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 Signs Someone Is Being Harmed More Than Helped by Pain MedicationThan Helped by Pain Medication
o Sleeping too much or having days and nights confused
o Decrease in appetiteo Inability to concentrate or short attention spano Mood swings (especially irritability)o Lack of involvement with otherso Difficulty functioning due to drug effectso Use of drugs to regress rather than to facilitate
involvement in lifeo Lack of attention to appearance and hygiene
Addiction Issues with Non-OpioidsAddiction Issues with Non-Opioids
o Many of the same questions apply when looking at use of o Muscle Relaxantso Cannabiso Other adjunctive medications –
Anticonvulsants Etc.
Adjunctive MedicationsAdjunctive Medicationso Topical – lidocaine, capsaicin,
antiinflammatories, othero Antidepressantso Anticonvulsantso Antiarrhythmic drugso Ultram
Antidepressants for PainAntidepressants for Pain
o Work by affecting neurotransmitterso Do not only work for treating pain by
improving depression.o Work as well in non-depressed people as in
people with depressiono Effectiveness for pain does not correlate with
effectiveness for depression
o Do not work for all types of pain.
Stopping or Tapering OpioidsStopping or Tapering Opioids
o Withdrawal Symptomso Anxiety/Restlessnesso Sweatingo Insomniao Diarrheao Nausea, vomitingo Yawning, rhinorrhea (runny nose)o Transient increase in pain
Treatment of WithdrawalTreatment of Withdrawal
o Each of the symptoms of withdrawal can be treated, and herbal support is also available for opioid withdrawalo Passionflowero Clonidineo Lomotilo Hydroxyzineo Trazodone o Etc.
