Scheduled vs Pain-Contingent Opioid Dosing

Time-Scheduled versus Pain-Contingent Opioid Dosing in Chronic Opioid Therapy – free full-text /PMC3098951/Jun 2012

This is an important topic for me because I’ve always taken my opioids on an “as needed” basis. Even when I have to take them every morning (as soon as my spine is compressed by gravity), the quantity varies according to my pain level, just as it does for the rest of the day. Some days I need twice as much as others, so taking them on a regular schedule doesn’t make sense for me.

Some expert guidelines recommend time-scheduled opioid dosing over pain-contingent dosing for patients receiving chronic opioid therapy (COT).

The premise is that time-scheduled dosing results in more stable opioid blood levels and better pain relief,…

This assumes that chronic pain is exactly the same all day every day, which may be true for some, but has not been my experience at all. 

Managing my medication so that the level is always enough for a worst-case scenario does not seem like a good idea for the wide fluctuations I experience.

I think doctors might hate PRN (as-needed) prescribing because it allows the patient to decide whether and when they need medication. However, from what I’ve heard and seen, there are some patients that are truly not capable of making good decisions about this.

...fewer side effects [addiction], less reinforcement of pain behaviors [addiction], and lower addiction risk.

Ah, here we see what they were really concerned about: not pain relief, but addiction.

We report results of a survey of 1781 patients receiving COT for chronic non-cancer pain, in which 967 reported time-scheduled opioid dosing only and 325 reported pain-contingent opioid dosing only.

We hypothesized that respondents using time-scheduled opioid dosing would report significantly fewer problems and concerns than those using pain-contingent dosing.

Patients receiving time-scheduled dosing received substantially higher average daily opioid doses than those using pain-contingent dosing (97.2 vs. 37.2 milligrams average daily dose morphine equivalents, p<.0001).

So taking opioids at regular intervals regardless of variations in pain results in almost 3 times the necessary dose.

Contrary to expectation, time-scheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (6.2 vs. 4.8, p=.008), after adjusting for patient and drug regimen differences.

Opioid-related psychosocial problems were somewhat greater among patients using time-scheduled dosing,

Time-scheduled dosing typically involved higher dosage levels and was associated with higher levels of patient concerns about opioid use.

My concern about scheduled dosing was always that I’d be taking opioids when my pain wasn’t high and potentially taking fewer opioids than needed when pain was severe.

Controlled comparative effectiveness research is needed to assess benefits and risks of time-scheduled opioid dosing relative to pain-contingent opioid dosing among COT patients in ambulatory care.

Again, they are assuming that “chronic pain” is a monolithic entity, when it actually varies widely, depending upon its origin.

This is the problem with all standard doses for opioids: not only do we metabolize them differently, but different types of pain may be much more variable than others.

A structured review on time-scheduled opioid dosing for post-operative pain management concluded that there is “sparse empirical work warranting endorsement of this dosing regimen.”

Subsequently, several trials of time-scheduled opioid dosing reported benefits relative to pain-contingent dosing in postoperative pain management. Whether findings for time-scheduled opioid dosing in post-operative pain management translate to COT in ambulatory care settings has not been examined.

Lack of evidence regarding the effectiveness of time-scheduled opioid dosing in ambulatory care is particularly salient given the dramatic increase in use of COT in community practice settings

Opioid dosing regimens may influence COT benefits and risks, so there is a need to understand the clinical implications of differences in how patients administer opioid analgesics for chronic non-cancer pain.

Although time-scheduled opioid dosing has been recommended in several guidelines, time-scheduled dosing could possibly result in

  • more frequent opioid administration,
  • higher cumulative opioid dose and

thereby greater potential for inducing tolerance, hyperalgesia and other dose-related adverse effects.

This proves I was right to reject time-scheduled dosing. The concerns listed here are exactly the ones I anticipated – and luckily avoided by following my own instincts in regard to my pain instead of listening to doctors with little pain experience of their own.

We hypothesized that CNCP patients using only time-scheduled opioid dosing would report lower levels of opioid-related psychosocial problems and would be less worried about their ability to control use of opioid medications.

And they were completely wrong.

It turns out that the patients themselves are better at monitoring and controlling their use of opioids than their doctors are. In general, it seems that doctors are reluctant to cede control to patients, even if they would benefit.

Long-term pain patients have a lot of experience with both their own pain and the effects of opioids on them, so they’re in the best position to decide when and how much opioid is needed.

Discussion

This cross-sectional study found that patients receiving chronic opioid therapy who exclusively used time-scheduled opioid dosing received substantially higher average daily doses than patients who used only pain-contingent opioid dosing.

Based on expectations that time-scheduled dosing should provide

  • more stable blood levels and analgesia,
  • reduce addiction risks,
  • yield fewer side effects, and
  • be less likely to reinforce pain behaviors,

we hypothesized that patients using opioids on a time-scheduled basis would report fewer psychosocial problems and opioid control concerns than patients with pain-contingent opioid dosing.

Contrary to these hypotheses, patients using exclusively time-scheduled opioid dosing reported similar levels of psychosocial problems attributed to use of opioids and higher levels of opioid control concerns than did patients with pain-contingent opioid dosing, after controlling for patient, pain status, and opioid use variables.

Patients using time-scheduled dosing reported being

  • more preoccupied with opioid use,
  • less able to control their opioid use, and
  • were more worried about opioid dependence.

They were also more likely to report that family or friends thought that they may be dependent on opioids.

Of course, they are dependent!

That’s a normal physiological response to consistent doses of medication, and very different from addiction, which is rare among pain patients.

These unexpected findings suggest that patients who employ time-scheduled opioid dosing differ from those who use pain-contingent dosing, and/or that hypothesized benefits of time-scheduled opioid dosing may not be realized in clinical practice.

This study came out in 2012 and it seems there has been no follow-up. Since it shows that current patterns of opioid dosing require higher doses, I don’t understand why this aspect has not been given more attention.

This cross-sectional study cannot establish the reasons for observed differences. However, these unexpected results do suggest that assumptions about benefits of time-scheduled opioid dosing need to be tested in controlled studies.

I think time-scheduled opioid dosing should be reevaluated and adjusted to accommodate the real-life experiences of the patient.

If patients are given leeway to take only enough to achieve relief, whether it be more or less than their “average”, most will avoid opioids when they can and use only the minimum effective dose. (because we fear increasing tolerance to increasing doses)

It is not particularly surprising that patients using time-scheduled dosing received higher opioid doses than did patients with pain-contingent dosing. These patients took opioids on more days per week, more times per day, and were more likely to use higher potency Schedule II opioids.

From this study it should be clear that time-scheduled dosing is inappropriate for most pain patients because it treats chronic pain as completely constant, no matter what the patient does.

That may be true of some kinds of pain, but not in most cases. Some days we have to do activities (shopping, errands, cooking, cleaning) that will worsen our pain and other days we can nurse it.

Physical therapists used to ask patients to prepare for their sessions by taking a pain medication beforehand. Otherwise, they wouldn’t be able to tolerate the exercises they need to improve their condition. That’s been my experience.

It’s truly ironic that we have to take pain medication now so that we won’t need it later.

22 thoughts on “Scheduled vs Pain-Contingent Opioid Dosing

  1. Judith Hizer

    I totally agree with your stance that PRN dosing makes more sense for a lot of patients. Unfortunately, at least around here, patients on opiods will lose their medication completely if the levels in their blood is not what is expected, at pain management clinics. The assumption is that they’re selling their medication.

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    1. Zyp Czyk Post author

      I wonder how sensitive those tests are. I don’t think the test would show a difference between taking a full or a half dose of our opioids – I think they can only detect the presence of a drug, not the concentration.

      I haven’t had an issue with my tests, but I can’t remember if they came after “high” or “low” dose days. I think I asked my doctor this exact question and she said it only tests whether you’ve taken at least some of your prescribed opioids.

      Of course, some illicit opioids break down to morphine, so I’m not sure how sensitive the tests are. It might also depend on the individual doctor and your relationship with them.

      My doctor and I have had a great relationship for about a decade and I have a feeling that if my test showed something strange she would talk to me about it, we’d figure out what caused it, and then she’d allow me to be tested again to confirm we straightened out whatever was causing the problem on the test. I’m incredibly lucky to have landed with such an excellent doctor.

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      1. canarensis

        I’ve always wished I had the $$ & pull to convince someone to do a time-course analysis on how my meds break down –like, lock me in an examining room, give me my usual dose of med, & take samples for analysis every hour for the next whatever time period –at least 24 hours. I have no idea if I’m one of the genetic fast metabolizers or something, but have always had incredibly high tolerance (even the first time I took pain meds) & what seemed like either very rapid clearance or very inefficient metabolizing of the meds.

        I too had a great doc for a long while who understood the one time I had a UA turn up totally clean when I knew damned well I’d swallowed my meds within the previous few days…days during which I had such a violent GI attack that nothing stayed in me long enough to be absorbed even a bit. She let me wait a few weeks to get over it, redid the test, everything was fine, & we went on happily. I still wish she hadn’t retired tho I understand totally why she did it (her cancer returned again).

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      2. Condo Minion

        Everybody has a really great doc at a point in their life. I did. Then he retired. New doc was young and chose not to treat my pain. This young one did not want to tarnish her shiny new doctor’s name tag with Norco.
        We will all, eventually, be left out in the cold.

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        1. Zyp Czyk Post author

          It’s hard not to wish our misery onto all these medical folks who deny use relief. But I believe they really don’t understand our suffering, thinking it’s just like an annoying “ache” that you should “get used to”. I may have thought that myself until it hit me too. Now I know that the body’s reaction to chronic pain is more like an allergic response, making it much worse instead of developing tolerance for the pain.

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    2. Condo Minion

      And because a large portion of EDS patients have a weird gene that shows zero opioids in their system, they get tossed out on their asses to commit suicide. I don’t currently take opioids because of the current manufactured hysteria, but I WILL need them soon and for the remainder of my life.
      Soooo, I’m screwed. Period.
      I’ve read of only one patient who demanded he be tested for this gene, and he was able to prove his opioid metabolism is rare, and the test cannot be trusted.
      That test is likely about $1300.

      The epidemic is suicides.

      Liked by 1 person

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  2. canarensis

    yet another Catch-22 position for us: when I first started seeing my now (thank heavens) previous doc, he asked me at the first 2-3 appointments if I took my meds “on the clock.” I’d never heard the phrase in that setting & figured I was being asked “do you take them as directed?” and answered “yes.” WRONG; turns out, for this guy taking them by the clock was proof that you were dependent & he’d joined the “physiological dependence is the same as addiction” crowd (thanks to seeing a single powerpoint presentation by our fave, Jane Ballentyne). So he cut me off. As further “proof” that that meds were doing me dire harm, he insisted that everything wrong with me was because of the opioids, ignoring, among many other large facts, that at least 3 of my conditions preceded me taking opioids by many years or multiple decades.

    Of course, if I’d said I didn’t take them on the clock but as needed, that would also have been proof that I wasn’t taking then as directed (i.e. abusing them) & cause for being cut off.

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  3. Condo Minion

    There was a couple “suggested articles” under this post. One of them has honest stats and proves there is no opioid epidemic.
    The writing is of appropriate tone for the writer and their audience, but I think Zyp could take the same data and write it in her style.
    I cannot write.
    Zyp, you are the best at clear, concise easy to read, not verbose, etc.
    Here is that post:
    https://wp.me/P2K3n4-Ow

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    1. canarensis

      that was a good story, stats-wise, tho I don’t agree with the slant that it’s all the pharmacos’ fault. I’ve not historically been a big fan of the pharmacos & the way they do biz (& it’s only a biz), but this “blame them b/c they have reeeeeeallly deep pockets we can stick out hands into” mind-set makes no sense. But it’s lucrative for all the greedy states. But if this really was a “prescription crisis” the OD rates wouldn’t have shot up in the 8 years since the Rx’s have plummeted, nor would the rise in drug use have been unrelated to the increase in prescriptions after they decided to actually treat pain, back in the (brief) good ole days. Drug use & ODs have stayed on the same trend since the 70s; it is not driven by pharmaco practices. The fact that the drug trends track completely the beginning of the “War on Drugs” is a lot more relevant (original Science article: https://science.sciencemag.org/content/361/6408/eaau1184. news story about it: https://www.nbcnews.com/storyline/americas-heroin-epidemic/opioid-crisis-started-40-years-ago-report-argues-n911456).

      btw, I was thrilled to see the ED non-connection mentioned…I read the Roger Chou review paper where that bullshite showed up, & it was the most egregious abuse of non-significant data I’ve seen in a while…& that’s saying a LOT these days.

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    2. Zyp Czyk Post author

      Wow, thanks for your faith in my writing!

      That’s an excellent article, similar to what I’ve seen from Richard Lawhern, who uses some of the same graphs. It’s stuffed with data and “connects the dots”, but my poor pained brain has a hard time following it.

      I will take another look later. Because I don’t know the author or the blog, I may just post it as a link.

      Liked by 1 person

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    1. Zyp Czyk Post author

      And the article contains an even better idea:
      “Using the method he and his colleagues developed, the Rutgers-Camden scholar is continuing his pain research utilizing fruit flies instead of mice.”

      Liked by 1 person

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      1. canarensis

        Oh goodie…they’re gonna start legislating our pain care based on the reactions & physiologies of insects. Brilliant.
        d’ya s’pose anyone will ever notice that people aren’t actually insects? Except of course for some of the louses behind this Age of Sadism…but that’s an insult to lice.

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        1. Zyp Czyk Post author

          And, what about chronic pain being a biopsychosocial issue? It’s always bothered me that our human pain is compared to rodent pain, and now insect pain.

          That’s fine for nociceptive pain because the physical nerve structures are very similar, but chronic pain is regarded as a completely different biopsychosocial problem, so how can any animal/insect research tell us anything about it?

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          1. canarensis

            Very good points. But hey, they sorta hit one out of 3 on “biopsychosocial,” so they’re actually doing better, for them.
            Again with the exception of political cockroaches & other certain suchlike persons, insects probably don’t get much in the way of psychological effects from pain. Tho I suspect they understand being in pain better than the aforementioned humanoids. Even mice & rats have more compassion & empathy when their fellow rodents are in pain than does society today have for us.

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    2. canarensis

      Kathy;
      The whole concept of rodent pain research sorta baffles me on a number of levels. I worked as a medical basic (not clinical) research technician for many years, & managed to avoid working with animals until the very last job, thank god. But before I was literally allowed to set foot in the animal areas, I had to do several hundred hours of training on how to handle them & generally work with them in ways that drastically minimized/eliminated their pain &/or mental or emotional discomfort. I’m sure not naive enough to believe that means they didn’t/don’t experience pain or discomfort or fear, but the supposed rules for the rats & mice were a helluva lot more strict than anything these days concerning humans (i.e. us, cancer patients, post-surgical patients….).

      Also, why the heck do they still insist on it when there’s no good way to really translate it into human terms? I’d much rather see politicians & Kolodny & Co in there in the little plastic cages, eating Purina Rat Chow* & being burned & pinched & so forth; it’d be a great deal more valid as far as human pain facts go. Satisfying, too. But that’s just further proof of how much of a curmudgeonly nutcase I am, I suppose. Having done basic research for many years, I understand you gotta look into related species, speculate, translate, etc, but…it sure ain’t ideal. Nothing is, unless they maybe started listening to the people (us) who’ve been subjects in decades’ worth of clinical research (“Naturalistic Experiments” as the Oregon zealots put it; that’s what they call the millions of patients they ripped pain meds from 2+ years ago. Tho how they can call it an experiment when they never spent a nano-second following up is beyond me). But of course, we’re just a bunch of addicts in denial, so why would anyone listen to us? ARGH.

      *it’s fitting

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  4. Kathy C

    I have been bouncing around here, https://twitter.com/PainReportsOPEN/. There are quite a few gems, lot of studies of placebos, and this, https://twitter.com/PainReportsOPEN/status/1134145708301459456

    “Pain-related perception of injustice may promote pain interference by hindering engagement in daily activities among individuals with #chronicpain.” Read #painreports #editorschoice #GYPainVulnerable https://bit.ly/2X32YpG

    Once again it is not the pain, or the imitations that causes, or the stigma implied by nonsense like this, it is the “feeling of injustice.” They even charted it. I bet the injustice rating goes up as the pain level increases. If the researcher is an A Hole, I bet those feeling of injustice and pain would increase. I wonder if they tested this on mice?

    They broke science! All we can expect is more of this!

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    1. Zyp Czyk Post author

      So it’s injustice we feel, not pain? There’s a lot of people who seem not to “believe in” chronic pain that’s absolutely a physical problem. They think pain becomes chronic because we’re thinking about it. These folks are in for a ruse awakening when it eventually happens to them.

      Liked by 1 person

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      1. canarensis

        Zyp & Kathy;
        Dear Lord, more BS from insane, idiotic correlations. While I admit that the degree of injustice we have to deal with is making me even crazier & certainly impacts my health (like all severe stress does…racism –i.e. injustice & stress– is probably the biggest single factor causing African Americans to have shorter lifespans & much poorer health than whites, even adjusted for age, socioeconomic status, education, etc)….oops, got lost in too complex a sentence. Yeah, injustice don’t help our health.

        But for them to say “increasing injustice correlates to [whatever]” is every bit as valid as the very strong correlation (94.71%!) between # of people who died by being tangled in their bedsheets & per capita cheese consumption (that & other insanely nonsensical but incredibly strong correlations at http://tylervigen.com/spurious-correlations. And you get to make up your own custom ludicrous graphs there, too! If you turned me onto that site, Zyp, thank you! I forget).

        Do these people EVER realize how asinine they are? (obviously not, stupid question. Sorry).

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