Effective Opioid-Based Pain Management and Patient Safety

The Balance Between Effective Opioid-Based Pain Management and Patient Safety: Can It Be Achieved?

“There is no question opiate/opioid drugs are the most effective analgesic medications available for the treatment of pain, regardless of cause.

The prompt and sustained relief of a patient’s pain is the goal of all caregivers. Although laudable, this goal is often difficult to achieve as pain is such a highly variable and individualized subjective symptom

Complicating effective pain relief are the multiple factors that influence a patient’s perception of pain, both presence and magnitude, including age, emotional state, previous pain episodes, cause of pain, and environment and culture, to mention a few. This variability in a patient’s perception and experience of pain underscores the difficulty in attempting to define population-based optimal dosing strategies for analgesic drugs.

Despite intense ongoing debate as to the best medication, the best regimen, and the best holistic approach to treating a patient’s pain, the opiate/opioid analgesics have for centuries remained a mainstay of effective pain treatment programs.

There is no question opiate/opioid drugs are the most effective analgesic medications available for the treatment of pain, regardless of cause. As noted above, the challenge is in designing the optimal, individualized, safe, and effective analgesic regimen that may or may not include or require an opioid

In this issue of the Journal, Whittaker describes the findings of a review of the literature addressing opioid-induced respiratory depression and death in children who received opioid medications postoperatively or following trauma. Respiratory depression evolving to respiratory failure and death is the most feared opioid-induced adverse effect

A number of clinically relevant adverse drug effects are associated with opioid drug administration, with one of the most common resulting from opioid-induced decreases in intestinal motility. Despite our knowledge and understanding of this expected and nearly universal pharmacologic effect, especially with aggressive opioid dosing, we often neglect to institute cathartic therapies early in the treatment course to avoid the associated constipation and possibly even impaction.

An abundance of data exists describing the primary endogenous opiate receptors including the mu (μ), kappa (κ), and delta (δ) receptors, which bind the endogenous opiate-like ligands beta-endorphins, enkephalins, and dynorphins.

Although still unresolved, it appears that most of the negative respiratory effects caused by opioids are a result of their binding to the μ receptor, the same receptor considered responsible for most of these drugs’ desirable analgesic effects.

Further complicating opioid drug effects on the respiratory system is the pain itself, as pain stimulates endogenous opiate-like compounds that bind to and modulate the same “opiate” receptors

The publications by Whittaker and these many others serve to remind us that only when active clinical observation is combined with a detailed understanding of a drug’s integrated pharmacokinetic-pharmacodynamic-pharmacogenomic profiles can one determine that important balance between effective opioid therapy and patient safety.

Pain management cannot be accomplished by some “standard of care” established for the “average” patient because it exists exclusively in a patient’s individual experience.  The medical treatment of pain must be completely individualized to be successful, and any efforts to establish standard dosing regimens only interferes and prevents doctors from providing the best care for their pain patients.




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