RESEARCH - Evidence mounting in support of opioids for chronic pain

[Guest guest]

Evidence mounting in support of opioids for chronic pain

Rheumawire

Jan 28, 2005

Gandey

Minneapolis, MN - A new study is adding to clinical evidence reassuring

physicians that opioids are an appropriate and safe treatment for patients

with chronic musculoskeletal diseases [1]. " Acceptance has been slow on the

part of the medical community to use opioids for chronic nonmalignant pain, "

lead author Dr Maren Mahowald (Minneapolis VA Medical Center and the

University of Minnesota) told rheumawire.. " Our study shows that opioids can

be effective in long-term persistent musculoskeletal pain. " The report

appears in the January 2005 issue of Arthritis & Rheumatism.

In their previous study of rheumatology-clinic patients, Mahowald and

colleagues found that opioid analgesics were highly effective and produced

only mild side effects, and they observed few instances of opioid abuse [2].

The purpose of this present analysis was to replicate the findings of the

previous study in another large cohort of patients with nonmalignant pain

due to well-defined spinal diseases.

" In an environment influenced by the metaphor of the 'war on drugs,'

patients with progressive disease and increasing pain are vulnerable to

inadequate treatment and/or suspicious evaluations by healthcare providers, "

the researchers write. " However, laws are changing. States are enacting

intractable-pain legislation that permits physicians to prescribe controlled

substances for intractable pain and prohibits medical boards from

disciplining physicians for long-term prescribing of a controlled substance

for intractable pain alone. "

Using a retrospective analysis of prescriptions and a cross-sectional

analysis of efficacy and toxicity by patient interviews, the researchers

looked at opioid use in 230 patients in an orthopedics spine clinic. Using

computerized pharmacy records, they determined opioid use and the stability

of the daily dose over a 3-year period. The investigators reviewed medical

records, operative reports, and radiographic studies to determine the reason

for dosage escalations and to detect instances of abuse or addiction

behaviors. They interviewed patients to determine the efficacy, frequency,

and types of side effects and instances of obtaining opioids from sources

outside of the study facility.

Mahowald and her team found that opioids were prescribed for 152 of the 230

patients. Of these, 94 patients received opioids short term (for less than 3

months) and 58 patients had long-term treatment. Medications prescribed were

codeine, oxycodone, propoxyphene, tramadol, morphine, meperidine, fentanyl,

or hydroxycodone, either alone or in combination.

The researchers completed interviews for 72 patients receiving short-term

opioid therapy, 50 long-term-therapy patients, and 45 patients not receiving

opioids. They found that pain severity was not different in patients with

different spinal pathologies. And they observed that opioids significantly

reduced the back-pain severity score from a mean of 8.3+SD 1.5 to 4.5+SD

2.2. The researchers note that mild side effects such as constipation and

sedation were reported by 58% of the opioid-treated patients but rarely

caused them to stop taking the medication.

They found no significant increase from the initial opioid dosage of

5.0+12.2 30-mg codeine equivalents per day to the mean peak dosage of

7.9+12.5 and the mean recent dosage of 4.3+6.3suggesting that tolerance to

opioid analgesia did not appear to occur in these patients. The researchers

observed dosage escalations of more than 2 30-mg codeine equivalents 19

times in 17 patients receiving long-term opioid therapy, 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%). The

investigators point out that these 3 patients also displayed other abuse

behaviors. And they found that abuse behaviors were not more frequent in

those with or without a history of addiction.

" This study demonstrated that opioid treatment of patients with well-defined

chronic pain of the spine was very effective, with mild toxicity, " the

researchers comment. " Opioid dosages were stable for prolonged periods of

time. Dosage escalations were typically related to an identifiable worsening

of the painful condition, a surgical complication, or an unrelated pain

process and did not appear to be due to the development of tolerance. "

In an interview with rheumawire, Mahowald said that it should be noted,

however, that this study did not address the question of opioid therapy for

pain of nonspecific etiology.

In an accompanying editorial, Dr Borenstein ( Washington

University Medical Center, Washington, DC) notes that nonsteroidal

anti-inflammatory drugs (NSAIDs) are most effective for inflammatory pain

and are less effective for acute nociceptive pain, while the opposite tends

to be true of opioids [3].

Borenstein writes that the role of a physician is to comfort the patient.

" Rheumatologists must give the treatment of pain in its various forms the

same priority we give to reducing erosions or normalizing complement levels.

The expeditious and effective treatment of pain reduces the potential for

permanent modification of the nervous system, resulting in a chronic pain

state. " He argues that opioids should be used in appropriate patients when

other nonopioid therapies result in inadequate pain relief or when the

potential toxicities of opioids have less risk. Opioids should be

discontinued, he says, if insufficient relief, intolerable toxicities, or

persistent noncompliance occurs.

Borenstein points to several limitations of the Mahowald et al study. He

notes that the retrospective nature of the work is limited by recall bias

with regard to pain relief and toxicities. " Prestudy prescription of opioids

for nonspine pain precluded the inclusion of a number of patients taking

long-term opioids, " he writes. " This group contained the fewest patients but

was of the greatest interest. Did the prestudy opioid patients have greater

difficulty with opioids, requiring additional or increased dosages of drugs

because of continuing pain? Did this cohort demonstrate a propensity for

drug-seeking behaviors? Was inefficacy of opioids for the relief of pain the

reason for a clinic consultation? "

Borenstein adds that mechanical disorders of the spine were the predominant

problems treated in the orthopedic spine clinic. However, the clinical

symptoms for which opioids were prescribed are not included in the study. He

wonders whether opioids were prescribed predominantly for back or neck pain,

arm or leg pain, or a combination of both. " These data could help clinicians

identify patients who are good candidates for opioid therapy. "

He continues, " Another issue concerns concomitant therapy. Were these

patients treated with opioids alone? Did they also receive NSAIDs? Were they

treated with physical therapy? Did individuals who did not receive opioids

have comorbid disorders that precluded their use? " Borenstein notes that he

would have also liked for the investigators to include information on

functional outcomes. " Data including the patient's global satisfaction with

therapy and improved function would strengthen the case for the use of

opioids in spine-disorder patients, " he writes.

The editorialist points out that the study does not measure the responses to

opioid therapy in women with spine disorders. The study population consisted

of 92.2% men. " Variations between the sexes do occur with regard to pain

perception and response to analgesic therapies, " he notes.

Mahowald told rheumawire that she commends Borenstein's review of their work

and his emphasis on important areas for future study. " did an

excellent job of describing the limitations of our study. "

But despite its limitations, Borenstein comments, " This study reports on a

large cohort of patients with spine disorders who obtained significant

levels of pain relief with opioid therapy without exhibiting tolerance,

toxicity, or abuse. " He continues, " Mahowald and coworkers should be

commended for studying orthopedic spinal disorders and publishing their

findings for a rheumatology audience. "

Sources

Mahowald ML, Singh JA, Majeski P. Opioid use by patients

in an orthopedics spine clinic. Arthritis Rheum 2005; 52:312-321.

Ytterberg SR, Mahowald ML, Woods SR. Codeine and oxycodone

use in patients with chronic rheumatic disease pain. Arthritis Rheum 1998;

41:1603-1612.

Borenstein D. Opioids: to use or not to use? That is the

question. Arthritis Rheum 2005; 52:6-10.

I'll tell you where to go!

Mayo Clinic in Rochester

http://www.mayoclinic.org/rochester

s Hopkins Medicine

http://www.hopkinsmedicine.org

[Guest guest]

Funny you should post this now. My last rheumy appointment was just a

few weeks ago and he said he wants to treat my pain with narcotics.

He has given my Vicodin to take as needed, but I am still having to

take steroids periodically inspite of the DMARDS I am on. He said he

would rather risk me going on narcotics daily than to be on steroids

at all!! i understand the reasons, given the effects of long term

steroid use, but because of my work, I can't/won't go on narcotic

therapy. I will probably have to give it up soon and do what he wants.

How is this for a kick in the butt...My insurance company sent me a

letter to inform me that the Enbrel I have been on will be bumped up

tier level so I will have a much higher co-pay. Their alternative

recommendation???....Methotrexate. Duh?!?! I wrote them a nasty

little letter telling them that if they took the time to see that I

was on Enbrel, then they should have noticed I was on methotrexate as

well. Those morons....I talked with the pharmacist at the insurance

company and he said that there was no appeal process for this and that

was their final decision. I told him that MTX alone doesn't work for

me and the Enbrel does. So, I told him that I guess I will have to go

back on Remicade every 4 weeks like before. I only pay an office visit

co-pay with that, but it is much more expensive. I get 1300mg a shot

and we were about to bump that up, too. Idiots!! Then the suggested

onther meds, for which I told them I can't take because Enbrel was the

only latex free product. The letter said they were happy to have me

as a customer. Yeah, right!! I think this customer would like a

refund!! Sorry about the bit**ing. Marina in Ohio