Randomised trial of oral morphine for chronic non-cancer pain

Long-term use of controlled-release oxycodone for noncancer pain: results of a 3-year registry study

OBJECTIVE

To evaluate the outcomes associated with the use of controlled-release (CR) oxycodone for up to 3 years in the treatment of noncancer pain.

METHODS

Adult patients who previously participated in controlled trials of CR oxycodone for osteoarthritis pain, diabetic neuropathy pain, or low back pain, and who continued to require opioid analgesia for moderate or severe pain, were enrolled in an open-label, uncontrolled, registry study. Data collected over time included dose, pain severity on a numeric scale, treatment acceptability, adverse events, and descriptions of problematic drug-related behavior.

RESULTS

Two hundred thirty-three patients were enrolled. When the study closed, 141, 86, and 39 patients had taken CR oxycodone for at least 1, 2, and 3 years, respectively; mean duration of treatment was 541.5 days. Among the 219 intent-to-treat patients (received at least 1 dose and provided at least 1 postdose study observation), the mean (SD, range) daily dose was 52.5 (+/-38.5, 10.0 to 293.5) mg. Before the end of month 3, 44% required an increase in total daily dose; this dropped to 23% during months 4 to 6, to 17% during months 10 to 12, and remained at approximately 10% for each time interval thereafter (range 8% to 13%). Among the large majority of patients with stable or lower dose requirements after the initial 3 months of treatment, the average pain intensity ratings were unchanged or improved for approximately 70% to 80% of patients at all subsequent time points through month 33, and for 54% (7/13 patients) at month 36. A decrease in pain was initially seen by the end of month 3, and for the majority of patients, the Average Pain Intensity score remained the same, better, or minimally worse (<3 points) for the remainder of the 3-year study period. The most common adverse events were constipation and nausea, and the incidence of these events declined over time on treatment. Investigators reported 6 cases (2.6%) of possible drug misuse but no evidence of de novo addiction was observed.

DISCUSSION

These registry data demonstrate that a subgroup of patients with noncancer pain experienced prolonged relief with tolerable side effects and modest need for dose escalation during long-term therapy with CR oxycodone.

Continuous Intrathecal Morphine Infusion in Patients With Vertebral Fractures Due to Osteoporosis

OBJECTIVES

Vertebral fractures are the most common consequences of severe osteoporosis. The chronic pain from collapse of osteoporotic vertebrae affects quality of life (QOL) and autonomy of patients. The management of pain with oral or transdermal opiates can cause severe side effects. Continuous intrathecal administration of morphine via an implantable pump might represent an alternative therapy to conventional oral or transdermal administration of opioids and has some advantages and disadvantages for pain relief and improvement in QOL when compared with conventional opioid delivery. It is our objective to report our experience using intrathecal delivery of analgesics in a population of patients with refractory pain due to vertebral fractures.

MATERIALS AND METHODS

In 24 patients, refractory to conventional delivery of opioids, we used intrathecal analgesic therapy. To test for efficacy and improvement in QOL, we administered the visual analog scale for pain and the Questionnaire of the European Foundation of Osteoporosis (QUALEFFO). Before patients were selected for pump implantation, an intraspinal drug delivery trial was performed to monitor side effects and responses to intrathecal therapy.

RESULTS

Significant pain relief was obtained in all implanted patients. Using the QUALEFFO, we observed significant improvement of all variables such as quality of daily life, domestic work, ambulation, and perception of health status, before and after 1 year after pump implantation. With intrathecal morphine infusion, none of the 24 patients required additional systemic analgesic medication. The mean morphine dose during the spinal trial was 11.28 mg/d, 7.92 mg/d at pump implantation, and 16.32 mg/d at 1-year follow-up.

CONCLUSIONS

Our results show that intrathecal administration of morphine efficiently relieves the symptoms of pain and improves QOL. Continuous intrathecal administration of morphine appears to be an alternative therapy to conventional analgesic drug delivery and has advantages in those patients who have severe side effects with systemic administration of analgesics.

Revisión sistemática: ¿son eficaces los opiáceos mayores en el tratamiento del dolor osteomuscular?

BACKGROUND AND OBJECTIVE

To evaluate the efficacy of major opioids in the treatment of musculoskeletal pain.

MATERIAL AND METHOD

Systematic review. A sensitive search strategy was undertaken in MEDLINE and EMBASE up to April 2005. The Cochrane Library and the abstracts of the 2004-2005 meetings of the American College of Rheumatology were also hand searched. All randomized controlled trials of major opiods in patients with musculoskeletal pain were selected. An analytical review was performed and evidence tables produced. A meta-analysis was run when appropriate.

RESULTS

We obtained 427 references from the search, (27 duplicated from MEDLINE and EMBASE, 2 from the Cochrane Library, and 5 abstracts), of which 68 articles plus one meeting abstract were selected for detailed analysis. Of these, 23 finally met the inclusion criteria. Combined analysis of oral major opioids versus placebo showed significant improvement in pain relief in patients with osteoarthritis.

CONCLUSIONS

Specific major opioids can reduce pain in patients with chronic musculoskeletal disorders. The clinical trials report positive effects on pain and the meta-analysis confirms these effects.

Opioids

Opioids are the most effective and widely used drugs in the treatment of severe pain. They act through G protein-coupled receptors. Four families of endogenous ligands (opioid peptides) are known. The standard exogenous opioid analgesic is morphine. Opioid agonists can activate central and peripheral opioid receptors. Three classes of opioid receptors (mu, delta, kappa) have been identified. Multiple pathways ofopioid receptor signaling (e.g., G(i/o) coupling, cAMP inhibition, Ca++ channel inhibition) have been described. The differential regulation of effectors, preclinical pharmacology, clinical applications, and side effects will be reviewed in this chapter.

Opioids for chronic nonterminal pain

This article first reviews the evidence for and against chronic opioid therapy. Evidence supporting the opioid responsiveness of chronic pain, including neuropathic pain, includes multiple randomized trials conducted over months (up to 8 months). Observational studies are conducted for longer, and many also support opioid analgesic efficacy. Concerns have arisen about loss of efficacy with prolonged use, possibly related to tolerance or opioid-induced hyperalgesia. Mechanisms of tolerance and opioid-induced hyperalgesia are explored. Evidence on other important outcomes such as improvement in function and quality of life is mixed, and is less convincing than evidence supporting analgesic efficacy. It is clear from current evidence that many patients abandon chronic opioid therapy because of the unacceptability of side effects. There are also concerns about toxicity, especially when opioids are used in high doses for prolonged periods, related to hormonal and immune function. The issue of addiction during opioid treatment of chronic pain is also explored. Addiction issues present many complex questions that have not been satisfactorily answered. Opioid treatment of pain has been, and remains, severely hampered because of actual and legal constraints related to addiction risk. Pain advocacy has focused on placing addiction risk into context so that addiction fears do not compromise effective treatment of pain. On the other hand, denying addiction risk during opioid treatment of chronic pain has not been helpful in terms of providing physicians with the tools needed for safe chronic opioid therapy. Here, a structured goal-directed approach to chronic opioid treatment is suggested; this aims to select and monitor patients carefully, and wean therapy if treatment goals are not reached. Chronic opioid therapy for pain has not been a universal success since it was re-established during the last two decades of the twentieth century. It is now realized that the therapy is not as effective or as free from addiction risk as was once thought. Knowing this, many ethical dilemmas arise, especially in relation to patients' right to treatment competing with physicians' need to offer the treatment selectively. In the future, we must learn how to select patients for this therapy who are likely to achieve improvement in pain, function and quality of life without interference from addiction. Efforts will also be made in the laboratory to identify opioids with lower abuse potential.

Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain

Although lumbar radicular pain is the most common chronic neuropathic pain syndrome, there have been few randomized studies of drug treatments. We compared the efficacy of morphine (15-90 mg), nortriptyline (25-100 mg), their combination, and a benztropine "active placebo" (0.25-1 mg) in patients with chronic sciatica. Each period consisted of 5 weeks of dose escalation, 2 weeks of maintenance at the highest tolerated doses, and 2 weeks of dose tapering. The primary outcome was the mean daily leg pain score on a 0-10 scale during the maintenance period. Secondary outcomes included a 6-point ordinal global pain relief scale, the Beck Depression Inventory (BDI), the Oswestry Back Pain Disability Index (ODI) and the SF-36. In the 28 out of 61 patients who completed the study, none of the treatments produced significant reductions in average leg pain or other leg or back pain scores. Pain reduction, relative to placebo treatment was, 14% for nortriptyline (95% CI=[-2%, 30%]), 7% for morphine (95% CI=[-8%, 22%]), and 7% for the combination treatment (95% CI=[-4%, 18%]). Mean doses were: nortriptyline alone, 84+/-24.44 (SD) mg/day; morphine alone, 62+/-29 mg/day; and combination, morphine, 49+/-27 mg/day plus nortriptyline, 55 mg+/-33.18 mg/day. Over half of the study completers reported some adverse effect with morphine, nortriptyline or their combination. Within the limitations of the modest sample size and high dropout rate, these results suggest that nortriptyline, morphine and their combination may have limited effectiveness in the treatment of chronic sciatica.

Opioids for neuropathic pain

Whether opioids are effective for neuropathic pain has been a matter of controversy for decades. Within limits, it is clear that opioids in general are effective for neuropathic pain. Furthermore, there is no evidence that opioids are any less effective for neuropathic pain than for non-neuropathic pain, no evidence that opioids are less effective for neuropathic pain than are other medications, and no evidence that one opioid is any more effective than another for neuropathic pain. It remains uncertain whether opioids are effective for central pain, although they may have a role. Although some patients appear to enjoy long-term benefits, most studies have been short-term. Opioids have an important role in the treatment of neuropathic pain; however, skillful opioid use balances the benefits with management of side effects and prevention and treatment of abuse and addiction.

Psychological factors in spinal cord stimulation therapy: brief review and discussion

✓Since its introduction in 1967 by Shealy and colleagues, spinal cord stimulation (SCS) therapy has become an accepted approach to the treatment of certain types of chronic pain. Significant advances have been made in surgical technique, hardware technology, and the variety of disorders for which SCS has proven to be potentially beneficial. Despite these advancements, 25 to 50% of patients in whom a preimplantation trial screening yields successful results report loss of analgesia within 12 to 24 months of implantation, even in the presence of a functioning device. Psychological factors may play an important role in understanding this observation and improving the outcomes.

In this article the author briefly reviews some of the data on psychological factors potentially involved in SCS. Research on patients with low-back and extremity pain was more heavily relied on because this is the population for which the most data exist. The discussion is divided into four sections: 1) role of psychological factors; 2) psychological screening and assessment; 3) patient selection and psychological screening; and 4) psychological variables and outcomes.

To date, the data remain speculative. Although few definitive conclusions can be drawn, the cumulative existing experience does lend itself to some reasonable recommendations. As with all therapies for chronic pain, invasive or noninvasive, the criteria for success and an acceptable level of failure need to be established, but remain elusive. The emphasis herein is to try to take what works and make it work better.

The DIRE score: predicting outcomes of opioid prescribing for chronic pain

The objective of this retrospective study was to test the validity and reliability of a scoring tool (the DIRE Score), for use by clinicians, that predicts which chronic noncancer pain patients will have effective analgesia and be compliant with long-term opioid maintenance treatment. DIRE scores were assigned to 61 cases from the pain center's databases. These cases were abstracted into vignettes that were reviewed and scored by 6 physicians. Repeat scoring was carried out on a subset of 30 vignettes after 2 weeks. The main outcome measures were: global impression of compliance and efficacy as indicated in the medical record and by interview with the patient's treating clinician; and final disposition, ie, whether or not opioids were continued or discontinued at the time of last clinical documentation. Internal consistency of the factors making up the DIRE Score was high (Cronbach's alpha = .80). Sensitivity and specificity of the DIRE Score for predicting patient compliance were 94% and 87%, respectively. For efficacy, sensitivity and specificity were 81% and 76%. For disposition, the sensitivity and specificity were 86% and 73%. Intraclass correlation was 0.94 for interrater reliability and 0.95 for intrarater reliability.

PERSPECTIVE

Public controversy about the use of long-term opioids for chronic pain fuels physician ambivalence about the prescribing process. In this initial retrospective study, validity and reliability of the DIRE Score are demonstrated. The score correlated well with measures of patient compliance and efficacy of long-term opioid therapy.

Addiction to opioids in chronic pain patients: a literature review

Opioids have proven very useful for treatment of acute pain and cancer pain, and in the developed countries opioids are increasingly used for treatment of chronic non-malignant pain patients as well. This literature review aims at giving an overview of definitions, mechanisms, diagnostic criteria, incidence and prevalence of addiction in opioid treated pain patients, screening tools for assessing opioid addiction in chronic pain patients and recommendations regarding addiction problems in national and international guidelines for opioid treatment in cancer patients and chronic non-malignant pain patients. The review indicates that the prevalence of addiction varied from 0% up to 50% in chronic non-malignant pain patients, and from 0% to 7.7% in cancer patients depending of the subpopulation studied and the criteria used. The risk of addiction has to be considered when initiating long-term opioid treatment as addiction may result in poor pain control. Several screening tools were identified, but only a few were thoroughly validated with respect to validity and reliability. Most of the identified guidelines mention addiction as a potential problem. The guidelines in cancer pain management are concerned with the fact that pain may be under treated because of fear of addiction, and the guidelines in management of non-malignant pain patients include warnings of addiction. According to the literature, it seems appropriate and necessary to be aware of the problems associated with addiction during long-term opioid treatment, and specialised treatment facilities for pain management or addiction medicine should be consulted in these cases.

Extended-release opioids for the management of chronic non-malignant pain

Recent clinical trials have documented the use of extended-release (ER) opioids in the management of chronic non-malignant pain. This manuscript reviews the clinical pharmacology of investigational and current marketed ER opioids. Recent randomised clinical trials of ER opioids that document the efficacy and safety of opioid therapy for chronic pain are reviewed. Finally, the abuse liability of ER opioids is discussed. Current technologies aimed at defeating the abuse of ER opioids will also be presented.

Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects

BACKGROUND

Chronic noncancer pain (CNCP) is a major health problem, for which opioids provide one treatment option. However, evidence is needed about side effects, efficacy, and risk of misuse or addiction.

METHODS

This meta-analysis was carried out with these objectives: to compare the efficacy of opioids for CNCP with other drugs and placebo; to identify types of CNCP that respond better to opioids; and to determine the most common side effects of opioids. We searched MEDLINE, EMBASE, CENTRAL (up to May 2005) and reference lists for randomized controlled trials of any opioid administered by oral or transdermal routes or rectal suppositories for CNCP (defined as pain for longer than 6 mo). Extracted outcomes included pain, function or side effects. Methodological quality was assessed with the Jadad instrument; analyses were conducted with Revman 4.2.7.

RESULTS

Included were 41 randomized trials involving 6019 patients: 80% of the patients had nociceptive pain (osteoarthritis, rheumatoid arthritis or back pain); 12%, neuropathic pain (postherpetic neuralgia, diabetic neuropathy or phantom limb pain); 7%, fibromyalgia; and 1%, mixed pain. The methodological quality of 87% of the studies was high. The opioids studied were classified as weak (tramadol, propoxyphene, codeine) or strong (morphine, oxycodone). Average duration of treatment was 5 (range 1-16) weeks. Dropout rates averaged 33% in the opioid groups and 38% in the placebo groups. Opioids were more effective than placebo for both pain and functional outcomes in patients with nociceptive or neuropathic pain or fibromyalgia. Strong, but not weak, opioids were significantly superior to naproxen and nortriptyline, and only for pain relief. Among the side effects of opioids, only constipation and nausea were clinically and statistically significant.

INTERPRETATION

Weak and strong opioids outperformed placebo for pain and function in all types of CNCP. Other drugs produced better functional outcomes than opioids, whereas for pain relief they were outperformed only by strong opioids. Despite the relative shortness of the trials, more than one-third of the participants abandoned treatment.

Does a Combination of Intensive Cognitive-Behavioral Pain Management and a Spinal Implantable Device Confer any Advantage? A Preliminary Examination

Research suggests that a combination of a somatic and a psychosocial intervention for chronic noncancer pain should be associated with a better outcome than either alone. This study presents data on a series of 31 patients who underwent sequential treatment with an implantable device targeting pain relief and a cognitive-behavioral pain management program that targeted improved function. A combination of treatments was used as there was a suboptimal response to the initial treatment. There were improvements in a range of outcomes at a long-term follow-up. Significant improvements were found in disability, affective distress, self-efficacy, and catastrophizing, but not in average pain severity. Further analyses failed to demonstrate an order effect. These results support the view that combined somatic and psychosocial interventions can achieve better outcomes than either alone in selected chronic pain patients. This approach requires that psychological assessment is essential before the use of an implantable device. This may not only improve patient selection, but also identify psychosocial factors that may be modified to enhance the effectiveness of invasive interventions. In addition, consideration for an implantable device following a suboptimal response to treatment in a cognitive-behavioral pain management program should include a re-evaluation of the patients' beliefs and use of self-management (coping) strategies before deciding on further treatment options.

Impact of Opioid Use on Outcomes of Functional Restoration

OBJECTIVES

To examine the effect of opioid use on psychological function, physical functioning, and return-to-work outcomes of a multidisciplinary rehabilitation program (MRP) for chronic pain.

METHODS

The participants were 127 patients with on-the-job injuries who had completed an MRP between 2001 and 2003. Opioid use was controlled by the patients' treating physicians (who were not affiliated with the MRP) and was assessed via patient self-report at the time of admission to the program and discharge. Other measures included pretreatment and posttreatment assessments of depression, pain severity, perceived disability, and physical ability (floor-to-waist lifting capacity). Return-to-work outcomes were obtained via follow-up phone calls approximately 6 months posttreatment.

RESULTS

Significant improvements from pretreatment to posttreatment were evidenced on all psychological and physical measures for both opioid users and nonusers. Further, there were no significant posttreatment differences between opioid and nonopioid users on psychological, physical, or return-to-work outcomes.

DISCUSSION

The role of opioids in the treatment of chronic pain continues to be controversial. Despite a lack of definitive data on their effectiveness, opioids continue to be prescribed, and thus patients using opioids continue to present for multidisciplinary rehabilitation. Although further exploration is warranted, results of the current study suggest that opioid use during rehabilitation does not necessarily preclude treatment success.

Predictors of opioid misuse in patients with chronic pain: a prospective cohort study

Background

Opioid misuse can complicate chronic pain management, and the non-medical use of opioids is a growing public health problem. The incidence and risk factors for opioid misuse in patients with chronic pain, however, have not been well characterized. We conducted a prospective cohort study to determine the one-year incidence and predictors of opioid misuse among patients enrolled in a chronic pain disease management program within an academic internal medicine practice.

Methods

One-hundred and ninety-six opioid-treated patients with chronic, non-cancer pain of at least three months duration were monitored for opioid misuse at pre-defined intervals. Opioid misuse was defined as: 1. Negative urine toxicological screen (UTS) for prescribed opioids; 2. UTS positive for opioids or controlled substances not prescribed by our practice; 3. Evidence of procurement of opioids from multiple providers; 4. Diversion of opioids; 5. Prescription forgery; or 6. Stimulants (cocaine or amphetamines) on UTS.

Results

The mean patient age was 52 years, 55% were male, and 75% were white. Sixty-two of 196 (32%) patients committed opioid misuse. Detection of cocaine or amphetamines on UTS was the most common form of misuse (40.3% of misusers). In bivariate analysis, misusers were more likely than non-misusers to be younger (48 years vs 54 years, p < 0.001), male (59.6% vs. 38%; p = 0.023), have past alcohol abuse (44% vs 23%; p = 0.004), past cocaine abuse (68% vs 21%; p < 0.001), or have a previous drug or DUI conviction (40% vs 11%; p < 0.001%). In multivariate analyses, age, past cocaine abuse (OR, 4.3), drug or DUI conviction (OR, 2.6), and a past alcohol abuse (OR, 2.6) persisted as predictors of misuse. Race, income, education, depression score, disability score, pain score, and literacy were not associated with misuse. No relationship between pain scores and misuse emerged.

Conclusion

Opioid misuse occurred frequently in chronic pain patients in a pain management program within an academic primary care practice. Patients with a history of alcohol or cocaine abuse and alcohol or drug related convictions should be carefully evaluated and followed for signs of misuse if opioids are prescribed. Structured monitoring for opioid misuse can potentially ensure the appropriate use of opioids in chronic pain management and mitigate adverse public health effects of diversion.

Using opioids with persisting noncancer pain: a biopsychosocial perspective

OBJECTIVE

Despite the growing use of opioids for persisting noncancer pain, evidence for their effectiveness is limited, especially in relation to functional outcomes. Guidelines have been developed for prescribers, but their utility is untested. This review examines the use of opioids in this population from a biopsychosocial perspective and makes a number of recommendations.

DATA SOURCES

Published comparison studies and reviews of oral opioids in chronic noncancer pain, as well as 5 published guidelines for the prescription of opioids and systematic reviews of cognitive-behavioral pain management programs.

METHODS

Outcomes of the opioid comparison studies were reviewed and compared to those achieved by pain management programs.

CONCLUSIONS

The available evidence indicates that by themselves, oral opioids generally achieve only modest reductions in pain levels in patients with chronic noncancer pain. Functional outcomes are inconsistent across studies. There are questions about the timing of their use and patient selection. There are risks in trials of opioids only after other conservative interventions have been tried unsuccessfully. Also, in some patients, ongoing use of opioids risks repeated over-doing of pain-generating activities and reinforcing escape/avoidance responses that promote disability. These risks may be lessened by assessment of current use of pain self-management strategies among potential candidates for opioids. This offers advantages in promoting collaborative management of persisting pain as well as better pain and functional outcomes. In this view, opioids may be considered as one possible element of a management plan rather than the primary treatment.

Percutaneous-guided pain control: exploiting the neural basis of pain sensation

The gastroenterologist deals frequently with painful conditions and suffering patients. Performing regular pain assessments and applying basic pain medicine principles will augment the care of patients in pain. Percutaneous-guided pain therapy techniques play a role in the multidisciplinary approach to pain medicine. Systemic opioid analgesia is the primary means of controlling cancer pain. However, 10% to 15% of cancer patients may need additional interventions to control pain. Sympathetic ganglion nerve blocks with neurolytic agents such as alcohol or phenol are reserved mostly for cancer pain. The efficacy and safety of these tools are validated by several decades of clinical application and published studies. Although the procedures are operator-dependent, in the hands of experienced clinicians, patients achieve sustained relief in the majority of cases. Although these techniques have been attempted in some benign conditions,such as chronic pancreatitis, with limited success, studies of newer imaging localization techniques such as endoscopic ultrasonography may expand future indications. Patients of the gastroenterologist who experience malignant abdominal pain may benefit from referral for percutaneous-guided pain control techniques.

The pharmacotherapy of chronic pain: a review

The past two decades have contributed a large body of preclinical work that has assisted in our understanding of the underlying pathophysiological mechanisms that cause chronic pain. In this context, it has been recognized that effective treatment of pain is a priority and that treatment often involves the use of one or a combination of agents with analgesic action. The current review presents an evidence-based approach to the pharmacotherapy of chronic pain. Medline searches were done for all agents used as conventional treatment in chronic pain. Published papers up to June 2005 were included. The search strategy included randomized, controlled trials, and where available, systematic reviews and meta-analyses. Further references were found in reference sections of papers located using the above search strategy. Agents for which there were no controlled trials supporting efficacy in treatment of chronic pain were not included in the present review, except in cases where preclinical science was compelling, or where initial human work has been positive and where it was thought the reader would be interested in the scientific evidence to date.

Do strong opioids have a role in the early management of back pain? Recommendations from a European expert panel

BACKGROUND

Since chronic low back pain (CLBP) is a complex biopsychosocial problem the ideal treatment is multimodal and multidisciplinary. However, in many countries, primary-care physicians care for many people with CLBP and have a pivotal role in selecting patients for more intensive treatments when these are available. Guidelines on the general use of strong opioids in chronic non-cancer pain have been published but, until now, no specific guidelines were available on their use in chronic low back pain. Given the prevalence of CLBP, and the complex nature of this multifactorial condition, it was felt that specific, evidence-based recommendations, with a focus on primary-care treatment, would be helpful.

METHODS

An expert panel drawn from across Europe including pain specialists, anaesthetists, neurologists, rheumatologists, a general practitioner, an epidemiologist and the chairman of a pain charity was therefore convened. The aim of the group was to develop evidence-based recommendations that could be used as a framework for more specific guidelines to reflect local differences in the availability of specialist pain services and in the legal status and availability of strong opioids. Statements were based on published evidence (identified by a literature search) wherever possible, and supported by clinical experience when suitable evidence was lacking.

RECOMMENDATIONS

Strong opioids have a role in the treatment of low back pain when other treatments have failed. They should be prescribed as part of a multimodal, and ideally interdisciplinary, treatment plan. The aim of treatment should be to relieve pain and facilitate rehabilitation.

Impact of long-term use of opioids on quality of life in patients with chronic, non-malignant pain

OBJECTIVE

The use of opioids in the management of non-malignant pain remains controversial. For many physicians, pain relief stemming from opioid use is not enough unless there is also a noticeable change in quality of life (QoL) and patient functioning. The impact of long-term opioid treatment on patients' QoL has been investigated in a limited number of trials, and these studies differ considerably with respect to their design and principal findings. This systematic review presents the results of these studies.

DESIGN AND METHODS

MEDLINE (1966 to November/December 2004), EMBASE (1974 to November/December 2004), the Oxford Pain Relief Database (Bandolier; 1954-1994) and the Cochrane Central Register of Controlled Trials (CENTRAL) were searched for relevant papers by combining search terms for function with terms for opioid analgesia, non-malignant and pain. Studies were eligible for inclusion if they met all of the pre-defined criteria specifying study design, population, intervention and outcome measures.

RESULTS

Eleven studies evaluated long-term treatment with opioids in patients with chronic, non-malignant pain and assessed QoL (N = 2877). Six studies were randomised trials and the remaining five were observational studies. In general, the former had higher Jadad rating scores for the quality of the paper than the latter. Of the four randomised studies in which baseline QoL was reported, three showed an improvement in QoL. Similarly, of the five observational studies, a significant improvement in QoL was reported in four.

CONCLUSIONS

There is both moderate/high- and low-quality evidence suggesting that long-term treatment with opioids can lead to significant improvements in functional outcomes, including QoL, in patients with chronic, non-malignant pain. However, further methodologically rigorous investigations are required to confirm the long-term QoL benefit of opioid treatment in these patients, and to elucidate the effect of physical tolerance, withdrawal and addiction, which are all associated with long-term use of opioids, on patients' functional status.

Langfristige Effekte von Opioiden bei Patienten mit chronischen nicht-tumorbedingten Schmerzen

A total of 121 patients with at least a 3-year history of opioid use were evaluated by a standardized interview during a clinical visit or telephone call. Assessed items were the present and former drug medication, daily doses, withdrawals, contentment with the treatment, positive/negative treatment effects, average/maximum pain and others.

STATISTICS

chi(2), ANCOVA and survival analysis. Of 121 patients (frequency of withdrawal 14.8% mainly due to lack of efficacy) with an average treatment time of 66 months (37-105 months; 80,264 days; 87% more than 5 years), 103 (85%) still took an opioid step II or III according to the WHO analgesic ladder. Patients further treated in the pain clinic stopped significantly less frequently than patients treated by GPs or other non-specialised physicians (5 versus 23%). Patients with long-term opioid intake revealed significantly lower pain intensity and higher contentment with the pain management and achieved improvement (global, quality of life and physical state). Changes of opioid dosages during the 5 years were inconsistent (no change 33%, decrease 16%, slight increase 27%, high increase 19%). However, the number of patients with high dose increased from 6 to 23 due to significant loss of efficacy (proved in the morphine subgroup, p<0.05). The survey demonstrates a very low frequency of withdrawal in patients with long-term opioid medication after initial response without evidence for tolerance development, especially if their treatment is controlled in a pain centre.

Opioid dosing trends and mortality in Washington State workers' compensation, 1996-2002

BACKGROUND

The use of opioids for chronic non-cancer pain has increased in the United States since state laws were relaxed in the late 1990s. These policy changes occurred despite scanty scientific evidence that chronic use of opioids was safe and effective.

METHODS

We examined opiate prescriptions and dosing patterns (from computerized databases, 1996 to 2002), and accidental poisoning deaths attributable to opioid use (from death certificates, 1995 to 2002), in the Washington State workers' compensation system.

RESULTS

Opioid prescriptions increased only modestly between 1996 and 2002. However, prescriptions for the most potent opioids (Schedule II), as a percentage of all scheduled opioid prescriptions (II, III, and IV), increased from 19.3% in 1996 to 37.2% in 2002. Among long-acting opioids, the average daily morphine equivalent dose increased by 50%, to 132 mg/day. Thirty-two deaths were definitely or probably related to accidental overdose of opioids. The majority of deaths involved men (84%) and smokers (69%).

CONCLUSIONS

The reasons for escalating doses of the most potent opioids are unknown, but it is possible that tolerance or opioid-induced abnormal pain sensitivity may be occurring in some workers who use opioids for chronic pain. Opioid-related deaths in this population may be preventable through use of prudent guidelines regarding opioid use for chronic pain.

Factor structure of the pain disability index in workers compensation claimants with low back injuries

OBJECTIVE

To examine the factor structure of a telephone-administered Pain Disability Index (PDI) and the effects of race and sex on the PDI.

DESIGN

Computer-assisted telephone interviews of a cohort with occupational low back injuries.

SETTING

General community.

PARTICIPANTS

Missouri workers compensation claimants (N=1329) with low back injuries.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

PDI, levels of pain severity, Social Security Disability Insurance status, and the Fear-Avoidance Behavior Questionnaire.

RESULTS

Results for the total sample and by race/sex group indicated support for a 2-factor model of the PDI corresponding to voluntary activities (eg, social, occupational, recreational) and obligatory activities (eg, activities of daily living, eating, sleeping). Additional psychometric analyses of the voluntary and obligatory subscales indicated adequate reliability and construct validity overall and in each of the race/sex groups. African Americans reported more pain-related disability on both subscales than whites. Women reported more disability on the voluntary subscale than men.

CONCLUSIONS

The results support use of the PDI as a bidimensional measure of pain-related disability, with strong psychometric properties. They also support its administration by telephone.

Age-dependent opioid escalation in chronic pain patients

Rapid opioid dose escalation, possibly caused by tolerance, has been observed in some patients on daily opioid therapy, although clinically identifiable characteristics of these patients are unknown. In this retrospective chart review of 206 patients, we examined whether the age of the patient was related to opioid escalation. Initial starting doses of long-acting opioids were similar in younger patients (< or =50 yr; 49 +/- 3 mg/d oral morphine-equivalent dose) versus older patients (> or =60 yr; 42 +/- 3 mg/d). Younger patients reached a maximum dose of 452 +/- 63 mg/d over 15.0 +/- 1.3 mo, whereas older patients achieved a maximum dose of 211 +/- 23 mg/d over 14.4 +/- 1.5 mo (P < 0.0001). At the last clinic visit, younger-patient dosing averaged 365 +/- 61 mg/d, with older patients averaging 168 +/- 18 mg/d (P < 0.0001). Only older patients demonstrated a reduction in visual analog scale scores from start of opioid therapy until discharge from the clinic (6.9 +/- 0.3 to 5.6 +/- 0.3; P < 0.01). These clinical data suggest that age is an important variable in opioid dose escalation. Although factors other than opioid tolerance can result in dose escalation, it is possible that older patients may have a reduced rate of tolerance development.

The drug-seeking patient in the emergency room

Drug-seeking patients include recreational drug abusers, addicts whose dependence occurred through abuse or the injudicious prescription of narcotics, and pseudoaddicts who have chronic pain that has not been appropriately managed. Opioids produce euphoria in some patients, providing the motivation for abuse, which can be detrimental even with occasional use. Even in the absence of overt euphoria, opioids are highly self-reinforcing and can be problematic in a large number of patients, requiring that acute care physicians exercise caution in whom they are administered. Habitual patient files, narcotic contracts, pain management letters, and patient tracking and management programs can be used for the benefit of both drug seeking-patients and chronic pain patients. For many patients, drug-seekers and chronic pain patients alike, withholding opioids may be an important part of their long-term management. For others, long-acting opioids such as long-acting morphine or methadone are a reasonable option.

Pharmacological alternatives for the alleviation of back pain

Drugs constitute a convenient option for low back pain and are commonly used. However, evidence for their efficacy is meagre. Many drugs used for back pain are no more, or only slightly more, effective than placebos. Others have side effects that outweigh their usefulness in relieving pain. On the basis of the evidence, no drug regimen can be legitimately recommended for back pain. The management of back pain requires measures other than drugs. One exception is the use of willow (Salix) bark for acute exacerbation of pain. Ironically, for chronic low back pain, the most effective and long-lasting outcomes have been documented for normal saline by injection into tender points in the lumbar spine.

An observational study of health-related quality of life and pain outcomes in chronic low back pain patients treated with fentanyl transdermal system

BACKGROUND

The analgesic effect of long-acting opioids, such as transdermal fentanyl, has been demonstrated in patients with cancer, neuropathic pain and chronic low back pain (CLBP). However, the broader effect of long-acting opioids on the patient's health-related quality of life (HRQoL) is less well known.

OBJECTIVE

To evaluate HRQoL outcomes in CLBP patients treated with transdermal fentanyl.

RESEARCH DESIGN AND METHODS

An observational study was conducted at 17 clinical centers in the US. Eligible patients had CLBP diagnosis for at least 3 months and were taking short-acting opioids chronically, and then initiated transdermal fentanyl treatment. Patients completed the Treatment Outcomes in Pain Survey (TOPS), which includes the SF-36 Health Survey, at baseline and > or = 9 weeks of treatment. The HRQoL burden of CLBP was determined by comparing CLBP patients' SF-36 scores to the general US population and low back pain patient norms. HRQoL outcomes were determined by comparing baseline and follow-up TOPS and SF-36 scores. Additionally, HRQoL outcomes were evaluated across patient groups stratified by changes in pain intensity ratings as measured by an 11-point numerical rating scale.

RESULTS

At baseline CLBP patients (N = 131) scored one-to-two standard deviations (SD) below age and gender adjusted SF-36 general population norms (MANOVA F = 127.1, p < 0.0001) and significantly lower than low back pain norms (MANOVA F = 125.3, p < 0.0001). At follow-up, significant improvement (p < 0.05) was observed on six of the SF-36 scales and both SF-36 summary measures and five of the six TOPS pain-related scales. The magnitude of change in scores in effect size units among these scales ranged from 0.17 to 0.80, which are considered small to large effect size changes. HRQoL score improvement was greatest among patients experiencing the greatest pain relief.

CONCLUSION

CLBP patients who chronically used short-acting opioids showed tremendous HRQoL burden. Favorable HRQoL outcomes were observed among patients who reported pain relief.

Opioids in chronic non-cancer pain: systematic review of efficacy and safety

Opioids are used increasingly for chronic non-cancer pain. Controversy exists about their effectiveness and safety with long-term use. We analysed available randomised, placebo-controlled trials of WHO step 3 opioids for efficacy and safety in chronic non-cancer pain. The Oxford Pain Relief Database (1950-1994) and Medline, EMBASE and the Cochrane Library were searched until September 2003. Inclusion criteria were randomised comparisons of WHO step 3 opioids with placebo in chronic non-cancer pain. Double-blind studies reporting on pain intensity outcomes using validated pain scales were included. Fifteen randomised placebo-controlled trials were included. Four investigations with 120 patients studied intravenous opioid testing. Eleven studies (1025 patients) compared oral opioids with placebo for four days to eight weeks. Six of the 15 included trials had an open label follow-up of 6-24 months. The mean decrease in pain intensity in most studies was at least 30% with opioids and was comparable in neuropathic and musculoskeletal pain. About 80% of patients experienced at least one adverse event, with constipation (41%), nausea (32%) and somnolence (29%) being most common. Only 44% of 388 patients on open label treatments were still on opioids after therapy for between 7 and 24 months. The short-term efficacy of opioids was good in both neuropathic and musculoskeletal pain conditions. However, only a minority of patients in these studies went on to long-term management with opioids. The small number of selected patients and the short follow-ups do not allow conclusions concerning problems such as tolerance and addiction.

Efficacy and safety of oxymorphone extended release in chronic low back pain: results of a randomized, double-blind, placebo- and active-controlled phase III study

This multicenter, randomized, double-blind, placebo- and active-controlled trial was conducted to compare the analgesic efficacy and safety of oxymorphone extended release (ER) with placebo and oxycodone controlled release (CR) in ambulatory patients with moderate to severe chronic low back pain requiring opioid therapy. Patients (N = 213) aged 18 to 75 years were randomized to receive oxymorphone ER (10 to 110 mg) or oxycodone CR (20 to 220 mg) every 12 hours during a 7- to 14-day dose-titration phase. Patients achieving effective analgesia at a stable opioid dose entered an 18-day double-blind treatment phase and either continued opioid therapy or received placebo. With stable dosing throughout the treatment phase, oxymorphone ER (79.4 mg/day) and oxycodone CR (155 mg/day) were superior to placebo for change from baseline in pain intensity as measured on a visual analog scale; the LS mean differences were -18.21 and 18.55 (95% CI, -25.83 to -10.58 and -26.12 to -10.98, respectively; P = .0001). Use of rescue medication was 20 mg per day. Adverse events for the active drugs were similar; the most frequent were constipation and sedation. Oxymorphone ER and oxycodone CR were generally safe and effective for controlling low back pain. Oxymorphone ER was equianalgesic to oxycodone CR at half the milligram daily dosage, with comparable safety.

PERSPECTIVE

Definitive studies of long-acting opioids in patients with chronic low back pain are lacking. We report the results of a multicenter, randomized, placebo-controlled, double-blind study evaluating the analgesic efficacy and safety of oxymorphone ER and oxycodone CR in opioid-experienced patients with chronic low back pain.

Management of Chronic Pain in the Acute Care Setting

Chronic nonmalignant pain requires evaluation and treatment different from acute pain. The pathophysiology is different, and there is commonly some degree of psychosocial dysfunction. Opioids tend to be much less effective as analgesics for chronic pain, and may increase the sensitivity to pain when given long-term. Because they are self-reinforcing, opioids may be sought and be reported to improve chronic pain, even when they may make the condition worse over time. There are many effective alternatives to opioids for the treatment of chronic pain, but their use is complicated and may require considerable time and effort to determine which ones work. Patients, particularly those who have already been prescribed opioids, may resist these alternatives. An extensive physical and psychosocial evaluation is required in the management of chronic pain, which is difficult if not impossible to achieve in the emergency or urgent care settings. Consequently, emergency and urgent care physicians should work closely with the patient's pain management specialist or personal physician. Systems should be set up in advance to identify those patients whose frequent use of acute care services for obtaining opioids may be compromising their long-term management, putting themselves at risk for psychological and tolerance-induced adverse effects of frequent opioid use. Opioids may be used in carefully selected patients in consultation with their pain management specialist or personal physician, but care must be exercised not to initiate or exacerbate psychological or tolerance-related complications of chronic pain.

Treatment of painful vertebral fractures by kyphoplasty in patients with primary osteoporosis: a prospective nonrandomized controlled study

This study investigates the effects of kyphoplasty on pain and mobility in patients with osteoporosis and painful vertebral fractures compared with conventional medical management.

INTRODUCTION

Pharmacological treatment of patients with primary osteoporosis does not prevent pain and impaired activity of patients with painful vertebral fractures. Therefore, we evaluated the clinical outcome after kyphoplasty in patients with vertebral fractures and associated chronic pain for >12 months.

MATERIALS AND METHODS

Sixty patients with primary osteoporosis and painful vertebral fractures presenting for >12 months were included in this prospective, nonrandomized controlled study. Twenty-four hours before performing kyphoplasty, the patients self-determined their inclusion into the kyphoplasty or control group so that 40 patients were treated with kyphoplasty, whereas 20 served as controls. This study assessed changes in radiomorphology, pain visual analog scale (VAS) score, daily activities (European Vertebral Osteoporosis Study [EVOS] score), number of new vertebral fractures, and health care use. Outcomes were assessed before treatment and at 3 and 6 months of follow-up. All patients received standard medical treatment (1g calcium, 1000 IE vitamin D(3), standard dose of oral aminobisphosphonate, pain medication, physical therapy).

RESULTS

Kyphoplasty increased midline vertebral height of the treated vertebral bodies by 12.1%, whereas in the control group, vertebral height decreased by 8.2% (p = 0.001). Augmentation and internal stabilization by kyphoplasty resulted in a reduction of back pain. VAS pain scores improved in the kyphoplasty group from 26.2 +/- 2 to 44.2 +/- 3.3 (SD; p = 0.007) and in the control group from 33.6 +/- 4.1 to 35.6 +/- 4.1 (not significant), whereas the EVOS score increased in the kyphoplasty group from 43.8 +/- 2.4 to 54.5 +/- 2.7 (p = 0.031) and in the control group from 39.8 +/- 4.5 to 43.8 +/- 4.6 (not significant). The number of back pain-related doctor visits within the 6-month follow-up period decreased significantly after kyphoplasty compared with controls: mean of 3.3 visits/patient in the kyphoplasty group and a mean of 8.6 visits/patient in the control group (p = 0.0147).

CONCLUSIONS

The results of this study show significantly increased vertebral height, reduced pain, and improved mobility in patients after kyphoplasty. Kyphoplasty performed in appropriately selected osteoporotic patients with painful vertebral fractures is a promising addition to current medical treatment.

[Effectiveness of a pharmaceutical care unit for the control of severe chronic pain]

INTRODUCTION

The effectiveness of a pharmaceutical care unit was assessed within a staged program for non-malignant severe chronic pain control in a multidisciplinary pain management unit at Consorcio Hospital General Universitario, Valencia, Spain.

MATERIALS AND METHODS

One hundred and fifty patients with clinical indication for a major opioid were included in WHO's third analgesic rung by our medical team following careful triage. The pharmaceutical care unit, or phase II, monitored dosage titration for pain stabilization with absence of side effects, as well as the onset of subsequent chronic therapy.

RESULTS

Upon program completion 75% of patients had their pain under control, having required 22.7 days on average for opiate dose titration. Mean daily dose was 22.3 mg, and constipation was prophylactically managed from the start. Fifty-nine percent of patients received subsequent chronic therapy with fentanyl transdermal patches at 25 microg/h; 10% followed suit with oral morphine solution, and 6% with controlled-release morphine. Twenty-five percent of the remaining patients had relevant events during the therapy titration stage, which led to therapy discontinuation and discharge because of lack of therapeutic effectiveness. After 24 months 70% of patients were still on initial doses.

CONCLUSIONS

The effectiveness of our unit was demonstrated by the achievement of the program objectives.

[Treatment of chronic pain in the internist's practice]

Chronic pain is one of the most frequent complaints in outclinic supply. Careful anamnesis and physical examination are in the focus of diagnostic procedure. Their results will give strong evidence for the underlying pathogenesis. Nevertheless, the perception of pain remains completely subjective and can be only measured by asking the patient. Therefore, a multitude of validated instruments has been developed ranging from the simple intensity rating scales up to sophisticated questionnaires. Both, the diagnostic and therapeutic procedures should adhere to the bio-psycho-social concept of pain. Medical treatment should be executed in accordance to the WHO Guidelines for Cancer Pain Treatment. But for the majority of patients, multidisciplinary concepts are required including psychotherapy and iatrophysics.

Drug seeking behavior

CONCEPT

Drug seeking behavior (DSB) is often mixed in illicit drug diversion confounding legitimate attempts to control acute and chronic pain.

OBJECTIVE

To review the literature of acute and chronic pain control against the medical and legal context of DSB.

DESIGN

Retrospective literature review from National Library of Medical Computerized Data Base 1990--2004.

PATIENTS

Preference to human prospective on retrospective clinical trials.

RESULTS

Drug use and abuse have significant adverse consequences. Pain control is desirable and necessary with chronic pain syndromes more prone to DSB. This behavior can be accurately profiled and information used to assist recovery.

CONCLUSION

It is desirable to address DSB stressing acceptance and a multidisciplinary approach to recovery.

Designing pain research from the patient's perspective: what trial end points are important to patients with chronic pain?

OBJECTIVES

The goals of this study were to define the endpoints of pain research that are important to patients with chronic pain and to identify clinical and demographic variables that are associated with patients' choices of endpoints.

PATIENTS & SETTING

Interviews were completed with 40 patients seen at the anesthesia pain clinic of an urban tertiary care medical center.

DESIGN

Each patient was presented with 4 brief (3-4 sentences) fixed information vignettes describing studies in which new medications would be evaluated. For each, patients were asked to describe how the medication being studied might offer an improvement over their current therapy.

OUTCOME MEASURES

Measures included structured qualitative analysis of responses, the Brief Pain Inventory, and Global Distress Index of the Memorial Symptom Assessment Scale.

RESULTS

Patients described a total of 20 endpoints. Individually, patients cited between 2 and 9 endpoints each (mean 4.9, standard deviation 1.7). Of these, the most commonly cited were decrease pain, decrease opioid dose, decrease frequency of scheduled dose, increased ability to function, decrease frequency of breakthrough dose, and improve sleep. Patients with severe pain cited more endpoints than did those with mild or moderate pain (mean 5.5 vs. 4.3; Rank sum test p = 0.01).

CONCLUSIONS

These data suggest that empirical research can provide data to guide the choice of endpoints in clinical studies of pain interventions.

A primary care, multi-disciplinary disease management program for opioid-treated patients with chronic non-cancer pain and a high burden of psychiatric comorbidity

Background

Chronic non-cancer pain is a common problem that is often accompanied by psychiatric comorbidity and disability. The effectiveness of a multi-disciplinary pain management program was tested in a 3 month before and after trial.

Methods

Providers in an academic general medicine clinic referred patients with chronic non-cancer pain for participation in a program that combined the skills of internists, clinical pharmacists, and a psychiatrist. Patients were either receiving opioids or being considered for opioid therapy. The intervention consisted of structured clinical assessments, monthly follow-up, pain contracts, medication titration, and psychiatric consultation. Pain, mood, and function were assessed at baseline and 3 months using the Brief Pain Inventory (BPI), the Center for Epidemiological Studies-Depression Scale scale (CESD) and the Pain Disability Index (PDI). Patients were monitored for substance misuse.

Results

Eighty-five patients were enrolled. Mean age was 51 years, 60% were male, 78% were Caucasian, and 93% were receiving opioids. Baseline average pain was 6.5 on an 11 point scale. The average CESD score was 24.0, and the mean PDI score was 47.0. Sixty-three patients (73%) completed 3 month follow-up. Fifteen withdrew from the program after identification of substance misuse. Among those completing 3 month follow-up, the average pain score improved to 5.5 (p = 0.003). The mean PDI score improved to 39.3 (p < 0.001). Mean CESD score was reduced to 18.0 (p < 0.001), and the proportion of depressed patients fell from 79% to 54% (p = 0.003). Substance misuse was identified in 27 patients (32%).

Conclusions

A primary care disease management program improved pain, depression, and disability scores over three months in a cohort of opioid-treated patients with chronic non-cancer pain. Substance misuse and depression were common, and many patients who had substance misuse identified left the program when they were no longer prescribed opioids. Effective care of patients with chronic pain should include rigorous assessment and treatment of these comorbid disorders and intensive efforts to insure follow up.

Opioid use by patients in an orthopedics spine clinic

OBJECTIVE

Concerns regarding the efficacy, toxicity, tolerance, dependence, and abuse of opioids have limited their use for patients with chronic spine pain. In our previous study of rheumatology clinic patients, opioid analgesics were found to be highly effective, produced only mild side effects, and had few instances of opioid abuse. The purpose of this study was to replicate our previous study in another large cohort of patients with nonmalignant pain due to well-defined spinal diseases.

METHODS

Opioid use was studied in 230 orthopedics spine clinic patients by retrospective analysis of prescriptions for 3 years and cross-sectional analysis of efficacy and toxicity by patient interviews. Opioid use and stability of the daily dose over 3 years were derived from computerized pharmacy records. Medical records, operative reports, and radiographic studies were reviewed to determine the reason for dosage escalations and to detect instances of abuse or addiction behaviors. Patients were interviewed to determine the efficacy, frequency, and types of side effects and instances of obtaining opioids from sources outside the Veterans Affairs system.

RESULTS

Opioids were prescribed for 152 of the 230 patients, for < 3 months (short-term [STO]) in 94, > or =3 months (long-term [LTO]) in 58, and none in 72 (no opioid [NTO]). Medications prescribed were codeine, oxycodone, propoxyphene, tramadol, morphine, meperidine, fentanyl, or hydroxycodone, either alone or in combination. Interviews were completed in 72 STO, 50 LTO, and 45 NTO patients. Pain severity (0-10 scale) was not different in patients with different spinal pathologies. Opioids significantly reduced the back pain severity score from 8.3 +/- 1.5 to 4.5 +/- 2.2 (mean +/- SD). Mild side effects (most commonly, constipation and sedation) were reported by 58% of the opioid-treated patients but rarely caused them to stop taking the medication. There was no significant increase from the mean +/- SD initial opioid dosage of 5.0 +/- 12.2 30-mg codeine equivalents per day (30 mg oral codeine = 5 mg oral morphine) to the mean peak dosage of 7.9 +/- 12.5 and the mean recent dosage of 4.3 +/- 6.3, suggesting that tolerance to opioid analgesia did not appear to occur in these patients. Dosage escalations of > 2 30-mg codeine equivalents occurred 19 times in 17 LTO patients and was due to worsening of the underlying painful condition, complications of spine surgery, or unrelated surgical or medical problems in all but 3 of them (5%). These 3 patients also displayed other abuse behaviors. Abuse behaviors were not more frequent in those with or without a history of abuse/addiction.

CONCLUSION

This study provides data on the efficacy, toxicity, tolerance, and abuse or addiction behaviors with opioid therapy in a large cohort of patients in an orthopedics spine clinic. The results provide objective data from patients with well-defined spine diagnoses to challenge the position that opioid treatment is inappropriate for chronic nonmalignant pain. This study provides clinical evidence to support and protect physicians treating patients with chronic musculoskeletal diseases, who may be reluctant to prescribe opioids because of possible sanctions from regulatory agencies. More important, it will benefit patients by permitting them to receive these effective, safe medications.

Benefits of transdermal fentanyl in patients with rheumatoid arthritis or with osteoarthritis of the knee or hip: an open-label study to assess pain control

OBJECTIVES

To evaluate the effectiveness and safety of transdermal fentanyl (TDF) for the treatment of pain associated with rheumatoid arthritis (RA) or osteoarthritis of the knee or hip (OA), which was not adequately controlled by non-opioid analgesics and/or weak opioids.

METHODS

The study design incorporated a 1-week run-in period when current analgesic medications were optimised, a 28-day treatment period and a 1-week taper-off period. Patients with RA (n = 104) and OA (n = 159) started treatment with TDF 25 microg/h. Patches were replaced every 72 h, with the option to up-titrate until adequate pain control was achieved. Metoclopramide was taken during the first treatment week and as needed thereafter.

RESULTS

203 patients completed the treatment phase, 90 entered the taper-off phase. 25 microg/h was the most frequently used maximum dose (51%). Pain control was increased from 4% to 29% of patients during run-in. The number of patients reaching adequate pain control in the first treatment week was increased to 75%, and increased further to 88% on day 28 and to 80% at endpoint. From baseline (screening) to endpoint, there were significant reductions in pain (p < 0.001) on the Wisconsin Brief Pain Inventory, and significant improvements in quality of life (Short-Form-36: physical p < 0.001; mental health p < 0.05). Eighty per cent of the patients (n = 134) assessed the treatment favourably; nausea and vomiting were the most common adverse events, mainly occurring at treatment initiation. Efficacy of metoclopramide appeared limited. TDF could be initiated in patients pre-treated with non-opioid analgesics or weak opioids and tapered off without major complications.

CONCLUSIONS

TDF significantly improved pain control and quality of life, and was well tolerated in patients with RA or knee/hip OA who continued to experience pain on their current analgesic treatment. Treatment could be discontinued without issues. Nausea and vomiting was usually mild during treatment initiation. Patients' well being could be further accommodated by optimising prophylactic treatment.

Eingeschr�nkte Wirksamkeit von Opioiden bei chronischen muskuloskelettalen Schmerzen

After excluding malignant disease in 21 patients with unremitting strong pain of the musculoskeletal system despite long-term opioid medication, the opioids were withdrawn to search for reasons of the limited effectiveness of the opioids. The opioid withdrawal was integrated in multimodal pain coping therapy. Besides the somatic diagnoses, pain-relevant psychosomatic diagnoses were evaluated with the structured clinical interview for DSM-IV (SCID). At the time of admission and discharge pain medication, physical functions, mood, and pain intensity were recorded. In the SCID interview, all patients were diagnosed with a relevant comorbid psychiatric condition (pain disorder, anxiety, depression). Despite reduction of the opioid medication, there was no increase of pain, but an improvement of the physical functions. In patients with chronic pain of the musculoskeletal system and limited effectiveness of opioid medication, psychosomatic comorbidities should be evaluated. Instead of continued and increased opioid medication, pain coping strategies and opioid withdrawal should be tested.

Randomised controlled trial of gabapentin in Complex Regional Pain Syndrome type 1 [ISRCTN84121379]

Background

Complex Regional Pain Syndrome type one (CRPS I) or formerly Reflex Sympathetic Dystrophy (RSD) is a disabling syndrome, in which a painful limb is accompanied by varying symptoms. Neuropathic pain is a prominent feature of CRPS I, and is often refractory to treatment. Since gabapentin is an anticonvulsant with a proven analgesic effect in various neuropathic pain syndromes, we sought to study the efficacy of the anticonvulsant gabapentin as treatment for pain in patients with CRPS I.

Methods

We did a randomized double blind placebo controlled crossover study with two three-weeks treatment periods with gabapentin and placebo separated by a two-weeks washout period. Patients started at random with gabapentin or placebo, which was administered in identical capsules three times daily. We included 58 patients with CRPS type 1.

Results

Patients reported significant pain relief in favor of gabapentin in the first period. Therapy effect in the second period was less; finally resulting in no significant effect combining results of both periods. The CRPS patients had sensory deficits at baseline. We found that this sensory deficit was significantly reversed in gabapentin users in comparison to placebo users.

Conclusions

Gabapentin had a mild effect on pain in CRPS I. It significantly reduced the sensory deficit in the affected limb. A subpopulation of CRPS patients may benefit from gabapentin.

The cognitive effects of opioids

Successful opioid therapy often depends on achieving a balance between analgesic effectiveness and side effects. The risk of opioid-induced cognitive impairment often hinders clinicians and patients from initiating or optimizing opioid therapy. Despite subjective experiences of mental dullness and sedation, objective tests of cognitive functioning do not always demonstrate marked changes following opioid administration. To guide clinical practice, as well as patient and family teaching, pain management nurses should be familiar with literature regarding this topic. The purpose of this article is to review the empiric literature on opioids and cognitive functioning, including the relationships among pain, cognition, delirium, and opioids. In general, research reflects minimal to no significant impairments in cognitive functioning. If impairment does occur, it is most often associated with parenteral opioids administered to opioid-naive individuals. Some evidence suggests that opioids may actually enhance cognitive function and decrease delirium in some patient populations. This article describes this research and explores the clinical implications of the research in this area.