Opioids in the Treatment of Chronic Pain: Legal Framework and Therapeutic Indications and Limitations

Trends in Opioid Dosing Among Washington State Medicaid Patients Before and After Opioid Dosing Guideline Implementation

By 2007, opioid-related mortality in Washington state (WA) was 50% higher than the national average, with Medicaid patients showing nearly 6 times the mortality of commercially-insured patients. In 2007, the WA Interagency Guideline on Opioid Dosing for Chronic Non-cancer Pain was released, which recommended caution in prescribing >120 mg morphine-equivalent dose per day for patients not showing clinically meaningful improvement in pain and function. We report on opioid dosing in the WA Medicaid fee-for-service population for 273,200 adults with a paid claim for an opioid prescription between April 1, 2006 and December 31, 2010. Linear regression was used to test for trends in dosing over that time period, with quarter-year as the independent variable and median daily dose as the dependent variable. Prescription opioid use among WA Medicaid adults peaked in 2009, as evidenced by the unique number of opioid users (105,232), the total number of prescriptions (556,712), and the total person-years of prescription opioid use (29,442). Median opioid dose was unchanged from 2006 to 2010 at 37.5 mg morphine-equivalent dose, but doses at the 75th, 90th, 95th, and 99th percentiles declined significantly (P < .001). These results suggest that opioid treatment guidelines with dosing guidance may be able to reduce high-dose opioid use without affecting the median dose used.

PERSPECTIVE

Some fear that opioid dosing guidelines might restrict access to opioid therapy for patients who could benefit. However, there is evidence that high-dose opioid therapy entails significant risks without demonstrated benefit. These findings indicate that high-dose opioid therapy can be reduced without altering median opioid dose in a Medicaid population.

Changes in opioid prescribing for Washington workers' compensation claimants after implementation of an opioid dosing guideline for chronic noncancer pain: 2004 to 2010

An opioid overdose epidemic emerged in the United States following increased opioid prescribing for chronic noncancer pain. In 2007, Washington State agencies implemented an opioid dosing guideline on safe prescribing for chronic noncancer pain. The objective of this population-based observational study was to evaluate opioid use and dosing before and after guideline implementation. We identified 161,283 workers aged 18 to 64 years with ≥1 opioid prescriptions in Washington Workers' Compensation, April 1, 2004, to December 31, 2010. Prevalence and incidence rates of opioid use were assessed. We compared pre- and postguideline chronic and high-dose use (≥120 mg/d) among incident users. The mean monthly prevalence of opioid use declined by 25.6% between 2004 (14.4%) and 2010 (10.7%). Fewer incident users went on to chronic opioid therapy in the postguideline period (4.7%; 95% confidence interval [CI], 4.5-5.0%) than in the preguideline period (6.3%; 95% CI, 6.1-6.6%). Compared with preguideline incident users, postguideline incident users were 35% less likely to receive high doses (adjusted odds ratio = .65; 95% CI, .59-.71). Although the extent to which decreases were due to the guidelines is uncertain, to our knowledge, this is the first report of significant decreases in chronic and high-dose prescription opioid use among incident users.

PERSPECTIVE

Evidence-based strategies for opioid risk management are needed to help abate the epidemic of opioid-related morbidity and mortality. The study findings suggest that opioid dosing guidelines that specify a "yellow flag" dosing threshold may be a useful tool in preventing escalation of doses into ranges associated with increased mortality risk.

Cancer pain management-current status

Cancer pain is still one of the most feared entities in cancer and about 75% of these patients require treatment with opioids for severe pain.The cancer pain relief is difficult to manage in patients with episodic or incidental pain, neuropathic pain, substance abuse and with impaired cognitive or communication skills. This non-systematic review article aims to discuss reasons for under treatment, tools of pain assessment, cancer pain and anxiety and possibly carve new approaches for cancer pain management in future. The current status of World Health Organization analgesic ladder has also been reviewed. A thorough literature search was carried out from 1998 to 2010 for current status in cancer pain management in MEDLINE, WHO guidelines and published literature and relevant articles have been included.

Trends in prescribed opioid therapy for non-cancer pain for individuals with prior substance use disorders

Long-term opioid therapy for non-cancer pain has increased. Caution is advised in prescribing for persons with substance use disorders, but little is known about actual health plan practices. This paper reports trends and characteristics of long-term opioid use in persons with non-cancer pain and a substance abuse history. Using health plan data (1997-2005), the study compared age-sex-standardized rates of incident, incident long-term and prevalent long-term prescription opioid use, and medication use profiles in those with and without substance use disorder histories. The CONsortium to Study Opioid Risks and Trends study included adult enrollees of two health plans, Kaiser Permanente of Northern California (KPNC) and Group Health Cooperative (GH) of Seattle, Washington. At KPNC (1999-2005), prevalence of long-term use increased from 11.6% to 17.0% for those with substance use disorder histories and from 2.6% to 3.9% for those without substance use disorder histories. Respective GH rates (1997-2005), increased from 7.6% to 18.6% and from 2.7% to 4.2%. Among persons with an opioid disorder, KPNC rates increased from 44.1% to 51.1%, and GH rates increased from 15.7% to 52.4%. Long-term opioid users with a prior substance abuse diagnosis received higher dosage levels, were more likely to use Schedule II and long-acting opioids, and were more often frequent users of sedative-hypnotic medications in addition to their opioid use. Since these patients are viewed as higher risk, the increased use of long-term opioid therapy suggests the importance of improved understanding of the benefits and risks of opioid therapy among persons with a history of substance abuse, and the need for more careful screening for substance abuse history than is the usual practice.

Opioids for nonmalignant pain

Pain is the most common symptom in the world for which patients seek professional help. Opioids offer an appropriate and safe treatment for some but not all patients with nonmalignant chronic pain. Potential risks, including drug abuse and intolerable side effects, appear to be manageable or even preventable in most cases. Patients with persistent rheumatic pain who have failed traditional treatments should be considered for long-acting opioids. Opioids are best administered in the framework of weighing the good against the bad in each patient, recognizing the potential morbidity and sometimes mortality in untreated patients who have severe and disabling pain daily.

Modern concepts of acute and chronic pain management

Both, acute and chronic pain should be treated using appropriate pain management as they may cause several negative reactions and jeopardise the health or at least the quality of life of the patients. Nowadays there are many analgesics and treatment tools available to provide sufficient pain relief for almost all patients. Unfortunately there are still patients suffering from pain due to inadequate or/and inconsequent pain therapy.