RESEARCH - Expert panel issues recommendations on opioids in low back pain

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Expert panel issues recommendations on opioids in low back pain

Rheumawire

Jun 14, 2005

Gandey

Vienna, Austria - An expert panel studying the use of strong opioids in

chronic low back pain reports that patients taking the maximum tolerated

dose of nonopioid analgesic treatment who continue to experience moderate or

severe pain that limits activity are usually good candidates for strong

opioids [1]. The European panel, consisting of pain specialists,

anesthetists, neurologists, and rheumatologists, among others, presented

their findings in a poster presentation here at the European League Against

Rheumatism (EULAR) 2005 meeting. " Prompt and appropriate treatment may

restore functionality, permit exercise and physical therapy, and reduce the

risk of the condition becoming chronic, " comment the researchers. " Strong

opioids should be prescribed as part of a multimodal and ideally

interdisciplinary treatment plan. "

The group's recommendations were the result of two consensus meetings and a

literature review that included other guidelines in this area. The panelists

point out that evidence-based recommendations could not be formulated

because of an absence of data. They note that among the many unanswered

questions that remain are the implications of long-term use, unknowns

regarding the possible interaction with psychosocial factors, and the effect

of opioids in younger patients. The work was funded by Janssen

Pharmaceutica.

The presenters, Drs Eija Kalso (Helsinki University Central Hospital,

Finland) and Serge Perot (Hôpital Cochin-Tarnier, Paris, France) on behalf

of the Chronic Low Back Pain Panel, report that therapies other than strong

opioids should be initiated first, but stronger therapies must be considered

if other options fail to achieve the desired outcome. But they say this is

not the case for subacute back pain, where strong opioid treatment should be

started immediately. And in patients younger than 50 without signs of

systemic disease, they note that symptomatic treatment without imaging is

appropriate. As a general rule, opioids should not be used as a substitute

for treating specific causes of pain unless pain is severe.

Red flags

The following indicating serious conditions that might cause

back pain and should be excluded before starting treatment:

Fever

Trauma

History of cancer

Unexplained weight loss

Widespread neurological changes

Erythrocyte sedimentation rate >50

The group notes that high-risk patients and those receiving long-term

treatment should always be evaluated at a multidisciplinary pain clinic.

They define strong opioids as members of the class that includes morphine,

fentanyl, and oxycodone, which act mainly at µ-opioid receptors to provide

analgesia.

Recommendations for treatment dosage and duration

The panelists call for a testing period of one to three months.

Starting dose and speed of titration based on clinical judgment.

Dose titration can be performed using sustained-release preparations,

which are safe for patients who have not previously received strong

opioid treatment.

Clear patient instructions about dosing are essential; an upper-dosage

limit should be set, but it should not be too low.

If treatment is effective but causes adverse effects, such as nausea

or somnolence, the physician should try to maintain treatment for

four weeks while treating the side effects, if patient agrees; most

adverse effects wane in that time.

If treatment with the first strong opioid is not successful, an

alternative should be tried.

Additional treatments, such as anticonvulsants, should not be started

during the test period.

The use of sustained-release formulations taken by the clock (rather

than as required) for continuous pain prevents peaks and troughs in

drug concentration.

A short-acting or nonopioid or weak opioid is preferred over

immediate-release strong opioids for breakthrough pain.

Prescribing immediate-release and short-acting strong opioids in

primary care is not recommended.

If both sustained-release and short-acting strong opioids are

considered necessary, the patient should be referred to a specialist

pain clinic.

Kalso and Perot caution that careful monitoring must be undertaken and

treatment duration limited. They add that treatment goals should be

realistic and individualized. And when using quality-of-life measures, they

recommend that clinicians determine which domains are significant to

individual patientsoften this will be functional status. A 10-cm visual

analogue scale (VAS) or 1 to 10 numerical rating score of three represents

satisfactory pain severity. A 30% reduction in pain correlates with patient

views that pain is much or very much improved.

Stopping opioid therapy

The recommendations state that the decision to stop therapy should be shared

by the doctor and patient. Conditions for stopping treatment should be

defined at the start of therapy and, where functional rehabilitation is the

aimas opposed to palliationearly down-titration should be attempted.

The group notes that, according to a World Health Organization report, after

six months off work, less than 50% of people with chronic low back pain

return to work; after an absence of two years, there is little chance of the

person returning. The cost to society of not curbing chronic low back pain

is therefore high, and prompt appropriate therapy is crucial.

Source

Kalso E, Perrot S. On behalf of the Chronic Low Back Pain

Panel. Recommendations on the use of strong opioids in low back pain before

it becomes chronic. EULAR 2005; June 8-11, 2005; Vienna, Austria. Abstract

SAT0360.

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Mayo Clinic in Rochester

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s Hopkins Medicine

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