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.
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.