Opioid Analgesics for Chronic Pain

By Mary Lou Bossio, NP

Chronic pain can be one of the more challenging conditions to manage, especially when it has been refractory to multiple modalities. An appreciation of chronic pain and its prevalence, along with thorough understanding of provider responsibilities, patient rights and the appropriateness of opioid analgesics for this population, are needed. Such knowledge provides a foundation for evaluating chronic pain and developing an individualized management plan. When opioids are used, prepare for both expected and unexpected results.

Chronic pain is pain without apparent biologic value that has persisted beyond the time in which normal healing should have occurred, usually 3 months.1 In 2004, chronic pain was internationally recognized as a major health care problem and a disease in its own right.2 Today, countless medical experts and health agencies contend that chronic pain should be treated with the same priority as the disease that caused it.3

History of Standards

The creation and endorsement of formal guidelines for the use of opioid analgesics in chronic pain management is relatively new. The American Pain Society (APS) and the American Academy of Pain Medicine (AAPM) issued a statement in 1996 to define when and how opioids should be prescribed for patients with chronic pain.4

Despite this formal position, pain continued to be undertreated due to fears of legal and criminal liability for prescribing controlled substances.5,6 This prompted the development and 1998 adoption of the Model Guidelines for the Use of Controlled Substances by the Federation of State Medical Boards of the United States.7 This document, which became policy in 2004, defines when opioids are appropriate for acute and chronic pain and details patient monitoring to deter drug diversion.8,9

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has issued standards on pain assessment and management. The standards, which took effect in 2001, state that all patients have the right to appropriate assessment and management of pain; that all patients should be assessed for pain and receive individualized care; that response to treatment should be monitored; and that treatment plans should be modified when necessary.10

Although the JCAHO standards provided a formal framework for pain management, they did not stipulate how appropriate management would be achieved, and a number of guidelines were subsequently issued.9-12The prevalence of guidelines and JCAHO standards today means that failing to prescribe appropriate medications constitutes undertreatment of pain and a departure from acceptable standards of practice.8

Opioid Need

An analysis of international s
tudies shows that 1 in 5 adults and 1 in 3 older adults experience moderate to severe pain lasting more than 3 to 6 months.1,13 A study of more than 3,500 primary care patients in the United Kingdom found that about half reported pain lasting more than 3 months.
14

And an international study that included the United States revealed that about 20% of more than 5,000 primary care patients experienced pain for more than 6 months.15 Put in everyday terms, as little as 1 in 10 and as many as 1 in 2 patients who present to a health care provider may have chronic pain.

Trends in Prescribing

Arthritis and other musculoskeletal disorders are the most frequently mentioned chronic health conditions significant enough to result in activity limitations among U.S. adults ages 18 to 64.16

An analysis of office visits and opioids prescribed for patients with musculoskeletal disorders in 1980 and 2000 revealed that office visits did not increase for these conditions. This analysis, which was based on data from the National Ambulatory Medical Care survey, also revealed that prescriptions for opioid analgesics for chronic pain doubled (8% to 16%), and the use of stronger opioid analgesics quadrupled (2% to 9%).17

The increase in opioid analgesic prescriptions is a sign that progress has been made in pain management.18-21 However, this trend has not allayed concerns that increased use of opioids would lead to more opioid abuse and addiction. As a result, studies were conducted to identify any abuse of opioid analgesics.

Opioid Use and Abuse

Three studies used two sources of data to analyze medical use and abuse of opioid analgesics from 1990 to 2002. These datasets included the Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS) and the Substance Abuse and Mental Health Services Administration’s Drug Abuse Warning Network (DAWN) for medical use and abuse.

The first study analyzed use and abuse of fentanyl, hydromorphone, oxycodone, morphine and meperidine from 1990 to 1996. Increased medical use did not appear to contribute to opioid analgesic abuse.19 The second study examined the use of fentanyl, morphine and oxycodone from 1997 to 2001 and documented similar results: Abuse was low despite increased medical use.20 The last study analyzed fentanyl, hydromorphone, oxycodone, morphine and meperidine use from 1997 to 2002.21 Increased medical use was associated with increased abuse but remained a small part of total DAWN mentions.

The increased use and greater availability of opioid analgesics for legitimate medical purposes further indicate progress in pain management.18-21 Increased opioid abuse, albeit a relatively small part of total abuse as defined in the three studies, emphasizes the need for continued vigilance to minimize nonmedical use.19-21

Evaluating for Opioid Use

Addressing a patient’s right to pain management and developing an appropriate treatment plan begin with a thorough evaluation of the patient and his or her pain complaint. This can be accomplished by focusing on four objectives:

  • Determine whether an appropriate workup has been completed and whether additional studies are warranted. Rule out an occult cause for pain, and identify any other etiologies.

  • Establish whether opioid analgesic use is indicated. Inadequate response to all appropriate nonopioid analgesics and nonpharmacologic interventions constitutes an indication.5,11,22,23 In addition, pathology must support the patient’s pain complaints. For opioids to produce analgesia through actions at opioid receptors and to modulate ascending and descending pathways, an identifiable pathology must exist.23-25 In the absence of pathology or noncorresponding pathology, exposure to and use of opioids can result in a continuum of behaviors ranging from change in affect to addiction.5,26,27 These events can also occur in the presence of corresponding pathology, with one distinct difference: A medical indication for opioid use existed.

  • Identify patients at risk for adverse consequences such as misuse or abuse of opioids. Pertinent positives will differentiate patients at risk (e.g., a remote history of alcohol abuse) or at higher risk and in whom opioid use is relatively or absolutely contraindicated (Table 1)9,23,28,29

  • Provide a baseline to compare effectiveness and adverse consequences related to planned interventions.
  • Developing a Treatment Plan

    Table 2 outlines key components of a pain history.4,7-9,11,23,29-34 This history is necessary to formulate the complete treatment plan. Table 3 shows an example of a treatment plan that includes opioids.9,29

    Discuss the risks and benefits of opioid therapy with each patient before prescribing it. This includes, but is not limited to, physical dependence, low risk of true addiction, potential for cognitive impairment, and the fact that pain may not respond to opioids.5,23 Some sources suggest using an opioid analgesic agreement (OAA) with all patients.8,11,30 Others recommend an OAA for patients who take opioids on a chronic basis.9,23,29,31,35

    T
    he OAA delineates patient and provider expectations and responsibilities. Common statements include the following: A single provider will prescribe and manage opioids, opioids are only taken as prescribed for the reason prescribed, and opioids will be continued as long as there is progress toward or attainment of therapy goals.

    The OAA should state that a drugs of abuse urine test (DAU) will be obtained periodically to monitor compliance-and that there are consequences to nonadherence. Reference 9 provides an example of an agreement.9

    Monitoring Outcomes

    Once opioid therapy is initiated, the efficacy and effects of therapy require ongoing assessment.29,36,37Efficacy is assessed by detailing whether analgesia and function have improved. Effects are assessed by detailing the presence or absence of adverse reactions and any adverse consequences. The latter requires having the expertise to identify appropriate and inappropriate use of opioid analgesics and taking actions to prevent misuse, abuse and diversion.

    The meaning of the terms misuse, abuse and addiction varies. One useful method to differentiate among behaviors places misuse at the beginning and addiction at the end of a continuum (Table 4).27,31,38,39

    Addiction cannot be diagnosed by a single event.29 However, patient behaviors have been categorized as being more or less suggestive of addiction.

    Behaviors that are less predictive of addiction include repeated requests for increased dose or quantity, drug hoarding when pain is less intense, requesting drugs by name, obtaining opioids from other medical providers or a nonmedical source, misuse, reporting effects not intended by the prescriber and occasional functional impairment.31,38,40

    Behaviors that are more predictive of addiction include the following: illegal behavior; accepting, borrowing or stealing drugs; altering or injecting an oral or transdermal opioid analgesic; concomitant use of alcohol or illegal drugs or prescription drugs from a nonmedical source; DAU positive for illegal substances, alcohol or other nonprescribed substances; abuse despite warnings; continued acquisition of opioids from another medical provider despite warnings, lost or stolen prescriptions; deterioration in function; resistance to therapy change despite deterioration in function; or repeated requests for early fills or dose increase despite evidence of adequate analgesia.31,38,40

    Preventing Inappropriate Use

    Actions that can prevent and detect inappropriate use include screening for alcohol and drug abuse with the pain history and a DAU before prescribing; use of an OAA; documentation of prescription fills and monitoring for pattern of early fills; clinic visits every 1 to 6 months with assessment and documentation of efficacy and effects at each visit; requiring clinic visits prior to change in dose or drug; requiring a police report for stolen prescriptions (only indicates a report was filed; does not verify theft); and random intermittent DAUs to monitor compliance, noncompliance and illicit substances use.9,38 The latter is not without caveats:

  • The level of some opioids may fall below the level for detection, resulting in a negative opiate result. This can be explained by metabolic rate or the cutoff concentration used by the lab. It also depends on when an opioid was last ingested, as well as dose and frequency of use.

  • A DAU will identify propoxyphene (Darvocet) and methadone. Presence of other opioids may only be detected and reported as positive for opiates.

  • A DAU will not identify the specific opiate.

  • Due to drug metabolism, additional testing may identify an opioid that has not been prescribed. Examples are hydrocodone (Vicodin) showing up as hydromorphone (Dilaudid) or hydrocodone and codeine showing up as morphine and codeine or morphine only.23,41,42

  • A positive test that is followed by consistently negative tests (three results) suggests diversion or overuse of opioids (running out).41

  • Heroin is quickly metabolized to morphine. Patients with a history of heroin use should not take this opioid, since the presence of morphine could indicate morphine use, heroin use or both.23,42 See references 23, 31, 35 and 42 for sources of interpretation for DAU results.23,31,35,42

    Consider DAU results in context with other behaviors that are not suggestive of or are highly suggestive of addiction. If a DAU result is unexpected, such as propoxyphene being detected when the patient does not have a prescription for it, meet with the patient. Discuss the results, and depending on the explanation, determine whether opioids should be continued. If uncertainty exists, consult with a pain management specialist. When there is evidence of illegal drug use such as cocaine, terminate therapy and refer to an addiction specialist.

    Putting It Into Practice

    The goal for clinicians in all settings is to responsibly offer opioid analgesic therapy to patients for whom it is indicated and justified. In addition, we must ensure that opioids are not being used for nonmedical reasons.

    It is unfortunate that the relatively small drug abusing population (6% to 15%) has led to an undertreatment of pain in the other 85% to 94%.43 Pain, unlike hypertension or a myocardial infarction, can’t be proved or disproved. Providers can be misled and deceived. However, if all patient reports of pain are valid and they receive the appropriate analgesics – including opioids when indicated and justified – two results are possible: Some patients without pain will get analgesics, or all patients with pain will get analgesics.

    We can try to minimize the risk of deception and provide pain relief for some, or we can accept the risk and ensure pain relief for all.44

    Mary Lou Bossio is an acute care nurse practitioner who provides pain management services in the Veterans Affairs Pittsburgh Healthcare System (VAPHS) in Pennsylvania. She is the codeveloper and consultant for the VAPHS Pain Resource Nursing Program.

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