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Chronic Pain Mar 1st, 2010

Opioid Therapy for chronic pain

While the use of opioids for chronic pain has gained increasing acceptance, in the opinion of many, there remains a dearth of quality research regarding the long-term effects of such medications in the chronic pain population. Controlled studies have yet to be published which confirm the best dosing regimen, the best way to identify potential abuse, and produce guidelines on predicting those who will benefit most from chronic opioid usage.

Despite this lack of solid research, chronic pain specialists’ general approach to the use of opioid treatment involves one of the following:

1. Due to the risk of addiction, tolerance and insensitivity to large doses of opioids, opioid medications should be tightly controlled, and the minimal dosage utilized as the ultimate goal of treatment.

2. Because opioids are so effective in the treatment of cancer pain, the risk of addiction and abuse have been greatly exaggerated. Ironically, it is therefore under-medication which causes non-compliance, and ultimately presumed treatment failure in the chronic pain patient. The goal should be adequate relief no matter the dosage, say the proponents of this approach.

There is a recently completed study examining these issues, headed by Dr. Naliboff of the Veterans Administration Greater Los Angeles Healthcare System. The data has yet to be fully digested, however. Naliboff examined a Tolerable Pain Dosage group versus an Adequate Relief Dosage group. The Tolerable Pain group was to have opioid medications prescribed at initially low doses, the expectation being that this will be adequate to bring pain to a tolerable level. In this group, dose increases were to be done slowly, with the goal of low and stable dosing as a means to prevent dependence and tolerance. In contrast, the Adequate Relief group was to have opioid dosage rapidly increased until the patient indicates satisfactory relief, at which point the dosage would continue going forward. For this Adequate Relief group, tolerance and dependence would thus be viewed as signs of inadequate opioid dosing. Of course, both groups were to be monitored with random drug screens.

The initial analysis of the data demonstrates significant correlations between affective measures of anxiety and depression, disability and opioid medication use. In fact, anxiety appears to better predict opioid use than a history of previous substance abuse. Depression may be the better predictor of disability. It will be interesting to see whether specific levels of anxiety/depression can predict the misuse of opioid medications. Of course, we all await the conclusions regarding pain relief, quality of life, addictive behaviors, mood, illness beliefs, treatment satisfaction, the frequency of visits to a health care provider, the impact of economic and social supports, the impact of past substance abuse, the type of chronic pain.

A bigger question remains once all the data is presented: What will chronic pain specialists do with conclusions which might very well clash with long-held assumptions-if not prejudices-when it comes to the chronic pain population?

Source: Psychology Today

Richard Lowes
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