OPIOID THERAPY IN CHRONIC PAIN

    Many clinicians cringe at the thought of prescribing or dispensing opioids, especially in high doses. The reasons for such trepidation are real, with rampant abuse and even fraudulent prescriptions, but the prevalence of misuse makes it more difficult for the legitimate pain patient to obtain appropriate and necessary therapy. The clinician must educate himself to recognize legitimate applications of even very high doses of opioids, not only for terminal illness, but for the patient with severe and unremitting pain who is expected to live for many years with the disability of chronic pain. He must also obviously be able to defend his prescribing or dispensing activities to regulatory agencies by appropriate documentation. A working knowledge of the rational clinical guidelines governing basal and breakthrough analgesia are essential for any clinician involved in such regimens.     
    While C-II agents are significantly more problematic when it comes to record-keeping and documentation, it must be recognized that they are also often substantially safer in long-term therapy than combination products incorporating acetaminophen, aspirin, or ibuprofen with an opioid. Physiological dependence is certainly a valid concern with pure opioids, especially in high doses and long-term therapy; but the end-organ liabilities and drug interactions of the additive agents (acetaminophen, aspirin, and ibuprofen) in high doses generally obviate the concern over dependence for the patient enduring appropriate long-term opioid therapy. Physiological dependence becomes a minor concern when suicide pursuant to an inability to live and function with severe and unrelenting pain becomes a patient’s only viable alternative. That may sound dramatic, but suicide is almost a ubiquitous ideation among patients enduring severe unrelenting pain, especially those for whom there may be no hope of improvement with modalities other than pain management.

Table 1: Combination analgesics can often produce more harm than benefit.

Aspirin and NSAIDs (even the COX-II inhibitors to some extent in high doses and prolonged therapy) can cause GI bleeding gastropathy, and ulceration;

NSAIDs can affect renal function, especially in the elderly; and their cardiovascular effects must also be considered; and

Acetaminophen in high doses and prolonged therapy should prompt evaluation of hepatic function, especially when given with other medications that might affect hepatic function and regular alcohol intake.

     While it is legally no less essential to document the clinical necessity for combination opioid products, the clinician must assiduously document the clinical necessity for high doses of pure opioid products, as well as develop a professional relationship with prescribers of such regimens, in order to justify frequent or continued dispensing of such agents. Recording diagnoses and documenting reasons for dosage adjustments can go a long way toward such justification when under scrutiny.      Similarly, the patient on high-dose opioids must get extra attention to be properly counseled on the potential consequences of long-term opioid therapy, including not only the bugaboo of physiological dependence; but the concepts of opioid tolerance, hormonal effects (effects on sex hormones and need for optimum thyroid function), and increased susceptibility to dental caries must also be brought to the patient’s attention. Most available patient information monographs fall woefully short in counseling the patient with chronic pain, a fact particularly true with adjuvant agents like anti-seizure or anti-epileptic drugs (AEDs), a plethora of anti-depressant agents routinely used in the control of chronic neurogenic pain syndromes, and seemingly unrelated agents like dextromethorphan/guaifenesin employed increasingly in treatment of various types of neuropathic pain.