Opioids Effective in Chronic Noncancer Pain

Opioids in chronic noncancer pain: More faces from the crowd Pain Res Manag | Jul-Aug 2012C Peter N Watson, MD FRCPC | free full-text PMC3411376

The present article contains 17 case reports of 11 CNCP conditions (followed to 2011) selected to illustrate specific issues from a survey of 84 patients with intractable CNCP treated with opioids and followed every three months for a median of 11 years.

Most patients in the total sample reported 50% or greater relief and a moderate improvement in disability.

Problematic use, tolerance and serious adverse effects, including constipation, were not major issues.  

These selected patient reports were chosen … to illustrate

  • important aspects of the diagnoses,
  • opioids and doses,
  • the paucity of intolerable adverse effects,
  • particular issues (concurrent addiction history, bipolar disorder and combination therapy),
  • disease-specific and other outcomes and
  • duration of follow-up with complex pain problems.

RESULTS:

Opioids were found to be safe and useful in the long term for these particular patients, as well as in the larger group from which they originated.

INTERPRETATION

These 17 reports of patients with intractable CNCP treated with opioids with some success over many years puts a face on more of the participants in the larger survey of 84 subjects, suggesting that this approach is effective and safe for some patients over many years.

The current debate raging about the long-term efficacy and safety of opioids in CNCP may be likened to the story of the different opinions of the blind men about the elephant.

In this tale, each individual has a different part of the beast in his hands and draws a different conclusion about its nature.

It is timely and of great importance that we document and put a face on the patients who benefit substantially, particularly in disease-specific ways and only from these drugs, for long periods of time safely.

CASE PRESENTATIONS

The following cases illustrate

  • a variety of CNCP types,
  • the variability in responsivity to different opioids and doses in the same condition,
  • the combination of different opioids and use with other analgesics to address different pain components,
  • the paucity of intolerable adverse effects,
  • the relief of more than one pain problem in an individual,
  • improvement in disease-specific outcomes and
  • tolerance to adverse effects as doses increase over time.

These 11 CNCP conditions in 17 patients treated with long-term opioid therapy begins with the most common form of CNCP:

  • chronic low back and neuropathic leg pain (three cases),
  • then painful diabetic neuropathy (two cases) and
  • postherpetic neuralgia (one case) (the most studied disorders for RCTs of opioids in CNCP),

and then moves to other less common and more intractable forms such as

  • brachial plexus neuropathy,
  • phantom limb pain (two cases),
  • causalgia (two cases),
  • osteomyelitis,
  • arthritis with Crohn’s disease,
  • chronic headache,
  • anesthesia dolorosa,
  • post-traumatic orthopedic pain and
  • the central pain of spinal cord vascular malformation (one case each).

The article then describes each of the 17 patients/cases in detail:

Case 1 (CM) (Figure 2): Chronic non-neuropathic low back pain, high-dose oxycodone

Case 1: CM seen with bearded dragon ‘Spike’. She was diganosed with mechanical low back pain and treated with high-dose oxycodone

Case 2 (VD) (Figure 3): Chronic low back and neuropathic leg pain, high-dose morphine

Case 2: On high-dose opioids for back and neuropathic leg pain, VD has been able to enjoy being with his grandchildren for many years. He was previously bedridden

Case 3 (KM) (Figure 4): Chronic low back and neuropathic leg pain, combination (fentanyl, oxycodone) low-dose opioids and initial sensitivity to several opioids

Case 3: Top KM works full-time with back and neuropathic leg pain while on long-term combination opioids (fentanyl/oxycodone).

I’m posting the first three case pictures because I want to show how totally normal people look even while taking significant doses of opioids to relieve their horrible pain.

You can read the detailed descriptions of all 17 cases/patients at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411376/

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