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      Challenges in Using Opioids to Treat Pain in Persons With Substance Use Disorders

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      Author(s): , M.D., M.S. 1 , 2 , 3 , , Ph.D. 4 , 5 , , Ph.D. 6
      Publication date (Print):
      Journal: Addiction Science & Clinical Practice
      Publisher: National Institute on Drug Abuse

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          Abstract

          Pain and substance abuse co-occur frequently, and each can make the other more difficult to treat. A knowledge of pain and its interrelationships with addiction enhances the addiction specialist’s efficacy with many patients, both in the substance abuse setting and in collaboration with pain specialists. This article discusses the neurobiology and clinical presentation of pain and its synergies with substance use disorders, presents methodical approaches to the evaluation and treatment of pain that co-occurs with substance use disorders, and provides practical guidelines for the use of opioids to treat pain in individuals with histories of addiction. The authors consider that every pain complaint deserves careful investigation and every patient in pain has a right to effective treatment.

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

          Eija Kalso, Jayne E Edwards, Andrew R. Moore … (2004)
          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.
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            Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects.

            Andrea D Furlan, Juan Sandoval, Angela Mailis-Gagnon … (2006)
            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. 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. 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. 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.
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              Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction.

              Bridget A Martell, Patrick G O'Connor, Robert D Kerns … (2007)
              The prevalence, efficacy, and risk for addiction for persons receiving opioids for chronic back pain are unclear. To determine the prevalence of opioid treatment, whether opioid medications are effective, and the prevalence of substance use disorders among patients receiving opioid medications for chronic back pain. English-language studies from MEDLINE (1966-March 2005), EMBASE (1966-March 2005), Cochrane Central Register of Controlled Clinical Trials (to 4th quarter 2004), PsychInfo (1966-March 2005), and retrieved references. Articles that studied an adult, nonobstetric sample; used oral, topical, or transdermal opioids; and focused on treatment for chronic back pain. Two investigators independently extracted data and determined study quality. Opioid prescribing varied by treatment setting (range, 3% to 66%). Meta-analysis of the 4 studies assessing the efficacy of opioids compared with placebo or a nonopioid control did not show reduced pain with opioids (g, -0.199 composite standardized mean difference [95% CI, -0.49 to 0.11]; P = 0.136). Meta-analysis of the 5 studies directly comparing the efficacy of different opioids demonstrated a nonsignificant reduction in pain from baseline (g, -0.93 composite standardized mean difference [CI, -1.89 to -0.03]; P = 0.055). The prevalence of lifetime substance use disorders ranged from 36% to 56%, and the estimates of the prevalence of current substance use disorders were as high as 43%. Aberrant medication-taking behaviors ranged from 5% to 24%. Retrieval and publication biases and poor study quality. No trial evaluating the efficacy of opioids was longer than 16 weeks. Opioids are commonly prescribed for chronic back pain and may be efficacious for short-term pain relief. Long-term efficacy (> or =16 weeks) is unclear. Substance use disorders are common in patients taking opioids for back pain, and aberrant medication-taking behaviors occur in up to 24% of cases.
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                Author and article information

                Journal
                Journal ID (nlm-ta): Addict Sci Clin Pract
                Journal ID (publisher-id): 101316917
                Title: Addiction Science & Clinical Practice
                Publisher: National Institute on Drug Abuse
                ISSN (Print): 1940-0632
                ISSN (Electronic): 1940-0640
                Publication date (Print): June 2008
                Volume: 4
                Issue: 2
                Pages: 4-25
                Affiliations
                [1 ] Dartmouth Medical School, Hanover, New Hampshire
                [2 ] Dartmouth Center on Addiction Recovery and Education, Hanover, New Hampshire
                [3 ] Manchester Veterans Administration, Medical Center, Manchester, New Hampshire
                [4 ] University of Kentucky, Lexington, Kentucky
                [5 ] The Pain Treatment Center of the Bluegrass, Lexington, Kentucky
                [6 ] Memorial Sloan-Kettering Cancer Center, New York, New York
                Author notes
                CORRESPONDENCE: Seddon R. Savage, 7764 Parker House, Dartmouth College, Hanover, NH 03755; e-mail: seddon.r.savage@ 123456dartmouth.edu .
                Article
                Publisher ID: ascp-04-2-4
                DOI: 10.1151/ascp08424
                PMC ID: 2797112
                PubMed ID: 18497713
                SO-VID: 9fc8e378-f18e-4fc8-8638-7fa75aae6ce8
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                Categories
                Subject: Clinical Perspective

                ScienceOpen disciplines: Health & Social care
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                ScienceOpen disciplines: Health & Social care

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