The case for Opiates – Daniel Brookoff; Hospital Practice, July 2000;
Opioid medications allow us to treat chronic pain as aggressively as we would any pathogen, but we must first overcome ingrained misconceptions about patients’ motivations for seeking treatment and about the addictive properties of the drugs. With controlled use, the newer sustained-release formulations give real hope for safe and sustained pain relief.
Less than 50 years ago, some medical textbooks discussed the need for patients to experience pain and suffering at the end of life so that they would relate to the agony of Christ and prepare for redemption. Although few physicians still hold these views, many continue to imply that pain should be accepted without complaint, telling their patients that “after all, pain is not going to kill you.”
There is growing evidence, however, that too much pain can cause damage and even death.When pain is controlled, medications for the underlying disease or disorder tend to work better. Opioid analgesia is one of the most prolife therapies that we have to offer patients with cancer pain, and there is no reason to think that patients with other diseases are any less deserving of relief or that their pain is any less amenable to treatment.
Assessment of Pain
Pain is generally assessed indirectly, which why it is so important to listen to–and believe–patients when they say that they are in pain.
Dr. DeLuca makes clear that this is the basic principle of treating pain: listening to and believing patients as they describe their experience with pain.
Some physicians apparently have difficulty with that. Many of my patients with chronic pain have been refused treatment by previous caregivers who apparently believed that their pain was not real. Even after undergoing painful procedures and surgeries that failed to bring relief, some of these patients were labeled as drug-seekers when they continued to ask for help. They had to contend not only with the pain but also with feelings of frustration, isolation, and abandonment by those on whom they had most relied.
I have found the following operational format to be particularly useful, both in gauging the severity of pain and in determining the degree of disability:
1) The patient’s perception. Asking the patient to keep a pain diary that includes numerical scales can help to objectify the pain. If it is understood that the physician will review the diary carefully, the patient will not have to act out a month’s worth of pain at every appointment. The diary can also be an important aid in identifying exacerbating or ameliorating factors and developing more effective strategies to cope with the pain such as behavioral changes or the preemptive use of analgesics in certain situations.
2) The patient’s emotional state and somatic preoccupation. This relates to the degree to which the patient remains focused on bodily symptoms to the exclusion of other issues
3) Functional status at home.
By keeping track of daily activities, both patient and physician have some measure of how disabling the pain actually is.
4) Functional status at work.
The number of work days missed and the specific work activities curtailed because of pain are also useful indices of pain severity
5) Use of analgesic medications.
If the patient is given an adequate supply of effective short-acting rescue medications and told to take them as needed, the number consumed can be a measure of pain.
The physician should make it plain that the other treatments are not designed to get the patient to stop using the pain medication but to stop needing it.
Too many people get this backwards: they think we should stop taking opioid pain medication first, then seek alternate means to control the pain (which may not even be possible). This is clear case of misguided priorities: see Treat Pain First—Worry about Psyche Problems Later
Setting Goals of Treatment
It is important that the physician and patient collaborate in developing the goals to guide treatment and the means to assess progress. In many cases, there is no realistic hope of cure, and patients must come to terms with the fact that treatment will probably continue for a long time. At first, the goals may be as simple as sleeping through the night, but as the patient’s condition improves, more ambitious goals, such as returning to work or participating in recreational activities, may be attainable.
In addition to reviewing the patient’s diary and keeping track of the various functional indicators, the physician must take the time to discuss the patient’s personal goals–what he or she has been missing because of pain and most wants to be restored.
Treating Suffering as Well as Pain
The ultimate goal in treating chronic pain is for patients to reclaim control of their lives, and, to do that, they must be relieved of suffering as well as pain. Issues such as sadness over lost opportunities, guilt for being a burden to others, and feelings of inadequacy or abandonment contribute to the suffering of many patients with chronic pain and deserve attention. Ensuring that the patient obtains good psychological care is just as important as providing analgesic medications.
Initiation of Opioid Therapy
In the United States, up to 90% of the prescriptions written for opioids are for noncancer pain. The efficacy and safety of these drugs in treating chronic pain syndromes has been demonstrated many times over. Most patients with chronic pain of moderate or greater severity who have not gotten good relief with disease-specific treatments or nonopioid analgesics should at least have a trial of an opioid medication, no matter what the cause of the pain. One of the most important ground rules for such a trial, as well as for subsequent treatment, is that a single physician must take full responsibility for establishing the protocol and writing all prescriptions.
Posttrial Therapy: Sustained-Release Opioids
These drugs have many important advantages over their short half-life counterparts. Because serum levels remain steady, miniwithdrawals or rebound reactions do not occur, as they sometimes do with long-term use of short-acting opioids. Sleep patterns are also more normal; with careful titration, the intermittent sedation that occurs with high-peaking, short-acting drugs is largely avoided.
Patients with chronic pain can often tell what has worked in the past and what has not. In one study of cancer patients using opioid analgesics, 44% required trials of two or more opioids, and 20% required three or more, before achieving satisfactory pain relief without intolerable side effects
Choosing the right opioid for a particular patient is usually a matter of guesswork. Even though opioids have been in use as long as any other class of medications, the base of knowledge on how to use them most effectively is surprisingly small, particularly with regard to combining them with nonopioid medications and with each other.
The opioid medications currently in use act largely through the mu-opioid receptor, but nearly all of them stimulate kappa- and delta-opioid receptors and some nonopioid receptors as well
There are also wide metabolic variabilities within groups of pain patients that may be determined by genetics or influenced by interacting drugs.
Titration Against Pain
Patients sometimes do well at the beginning of opioid therapy and then seem to lose ground within a few weeks. In those who have been severely limited in their activities, the recurrence of pain is not necessarily a sign of growing tolerance to the medication–the patient may be experiencing more pain because of increased activity and should be reassured that more medication is required to alleviate the pain of someone with a busy schedule than of someone lying in bed all day.
The most feared side effect of opioid medications is respiratory depression. This does not occur, however, when the drugs are titrated against the patient’s pain, probably because the pain signals activate respiratory centers in the brain that counterbalance depressive effects
One can be assured that a patient who is awake and complaining of pain is not in any imminent danger of respiratory depression.
If the source of pain is abruptly removed, an opioid dose that is well-tolerated can suddenly become sedating
Nausea occurs in 10% to 40% of patients treated with opioids. If they are getting good pain relief, there is no need to withdraw or reduce the medication. Antiemetics such as promethazine or prochlorperazine, both of which are available as pills and suppositories, are usually effective when used three to four times a day for a few days
Hives or itching may occur at the beginning of therapy with certain opioids as a result of their direct effect on mast cells. These problems are more commonly seen with the naturally occurring opiates (e.g., codeine or morphine) than with synthetics.
Initiation or escalation of opioid medications can produce sedation or somnolence in some patients. However, those with severe pain may feel more alert or normal
The one common persistent side effect of opioid use is constipation, which is mediated by opioid receptors in the bowel. More than half of patients on sustained-release opioids experience constipation requiring specific therapy.
It is important to get patients on a good bowel regimen as soon as possible and to teach them to adjust their bowel medications as needed.
Tolerance to Opioids
That most adverse side effects of opioids resolve on their own is an indication of growing tolerance with continued use. Tolerance can also be conferred by other factors. Severe pain, for example, allows patients to tolerate the sedative effects of opioids
Whether tolerance develops to the pain-relieving effects of opioids is a matter of controversy. Most of the data on opioid tolerance and physical dependence in humans involves subjects who were not in pain. Studies of patients with chronic pain who have taken opioids for a long time indicate that once the dose required for pain relief is established, it generally remains stable unless the underlying disease progresses.
Physical Dependence on Opioids
With long-term use of opioids, patients will experience physical symptoms (abdominal cramping, sweating, nausea, diarrhea, irritability) if the medication is abruptly withdrawn or the dose is markedly reduced. This type of physical dependence is not limited to opioids but can occur with other drugs such as antihypertensives and steroids
Withdrawal symptoms are easily avoided by using a tapering regimen when lowering the dose. This can nearly always be done, without discomfort, in an outpatient setting.
Appropriate Use Versus Abuse
The inappropriate use of a medication for a nonmedicinal problem is drug abuse. Using a pain medication to get high or euphoric is clearly inappropriate, as is using drugs to escape family or other problems that should be dealt with by other means. If a patient’s physical pain has prevented him or her from living life fully, using a medication that allows a return to normal activities cannot be called drug abuse.
The appropriate role of medicine is to prolong and maintain life, promote function, and provide comfort from symptoms of disease. It is up to the physician to determine whether the prescribed medications are being used to participate in life or to escape from it
Addiction and Pseudoaddiction
Taken to the extreme, drug abuse can become drug addiction, a driving force that leads to compulsive, socially inappropriate, or even dangerous behaviors. The overwhelming majority of drug addicts report that their addiction began with recreational drug use. Medical use of opioids is generally not associated with addiction.
The most important predictor of continued abuse or addiction is previous substance abuse.
Denied the pain treatment to which they are entitled, patients often say that they feel isolated, anxious, and even desperate. The obsessive and manipulative behaviors that these feelings engender, which can sometimes be confused with addiction, are called pseudoaddiction
Russell Portenoy’s tabulation of drug-seeking behaviors is a useful reference for discriminating between addiction and pseudoaddiction (Table 2).
Table 2. Behavioral Assessment of Drug Abuse or Addiction Predictive Behaviors Selling prescription drugsObtaining prescription drugs from a nonmedical sourceStealing or borrowing drugs from othersUsing illicit drugs or abusing alcoholInjecting oral formulationsEscalating dosage or otherwise not complying with therapy despite repeated warnings
Seeking prescriptions from other physicians without informing the prescriber or after being warned to stop
Demonstrating functional deterioration related to drug use
Resisting changes in therapy repeatedly despite adverse drug effects
Nonpredictive Behaviors Complaining aggressively about the need for more medicineHoarding drugs during periods of reduced symptomsRequesting specific medicationsEscalating dosage or otherwise not complying with therapy on only one or two occasionsUsing medication to treat unrelated symptomsReporting psychic effects not intended by the physician Adapted from Portenoy, 1994
Treating Chronic Pain: Healing the Incurable
Opioids are usually reserved as a last resort for the treatment of pain, but it may be time to consider using them to rescue patients in severe pain who have not responded to disease-specific treatments or mild analgesics. Once some relief is achieved, adjuvant medications and nonpharmacologic or more aggressive approaches can be tried. In my experience, most treatments work better when there has been some initial pain relief
it is very easy to become judgmental when faced with a patient whose suffering is difficult to understand. Unfounded assumptions are harmful and can rob a suffering patient of hope. With our current knowledge of how pain is generated and alleviated, it is both disrespectful to the patient and a breach of medical ethics not to provide what is clearly needed
When a patient in chronic pain seeks our help, the first question we should ask ourselves is not whether we should provide an analgesic but whether we can in good conscience leave that person in pain.
To quote Marcia Angell, “Few things a doctor does are more important than relieving pain. . . pain is soul destroying. No patient should have to endure intense pain unnecessarily. The quality of mercy is essential to the practice of medicine; here, of all places, it should not be strained.”