Opioids May Be Useful for Chronic Noncancer Pain Management in Primary Care

October 12, 2007 — A review article in the October issue of the Southern Medicine Journal indicates the proper administration of opioids for chronic noncancer–associated pain management in the primary care setting.
"Over the past decade, the pattern of chronic pain treatment in the United States resembles a pendulum, swinging first in one direction and then in the other, seeking only recently a modulated and more neutral resting position," write Bruce Nicholson, MD, and Steven D. Passik, PhD, from the Pain Specialists of Greater Lehigh Valley in Allentown, Pennsylvania. "Since patients with chronic noncancer pain are a more heterogeneous population than patients with chronic cancer pain, and frequently have multiple comorbidities, the results of treatment with opioid analgesics were, not surprisingly, more mixed than in tertiary care cancer populations.... In order for the pendulum to attain a modulated, more neutral resting position in which patients with chronic noncancer pain receive adequate analgesia, it is essential to present healthcare providers with necessary factual information to address their clinical and medicolegal concerns."
Although opioids are considered to be the mainstay of chronic pain management, their use is controversial for many primary care clinicians concerned about dependence, abuse, addiction, and medicolegal issues regarding state and federal regulatory authorities. Although these concerns exist, opioids are thought to be effective and safe in selected patients, and their use in this setting is consistent with clinical practice guidelines and regulatory policy statements.
Patients with chronic, noncancer–associated moderate to moderately severe pain typically require a controlled-release formulation of a long-acting opioid or opioid combination drug product that will offer sustained pain relief, as well as better sleep quality, compliance, and sometimes quality of life. These drugs allow around-the-clock administration, resulting in constant systemic drug levels and decreased potential for end-of-dose failure.
In treating patients with chronic, moderate to moderately severe pain, immediate-release opioid formulations should be used to provide analgesia when breakthrough pain occurs.
Before starting patients on long-term opioid therapy, it is essential to identify patients who may have difficulties in managing opioids or who will develop dependence, abuse, or addiction. Careful screening with validated questionnaires can be helpful in this regard. Although these patients should not be denied treatment with opioids, focused monitoring and case management are crucial.
The 4 A's are a useful mnemonic for ongoing monitoring: analgesia, activities of daily living, adverse effects, and aberrant drug-related behaviors. Healthcare providers should be able to distinguish between the physical and psychological effects of opioids and to classify patients with low, moderate, or high risk for substance abuse and/or addiction based on careful screening. Based on their risk category, patients should be monitored for the 4 A's at appropriate intervals. Clinicians must thoroughly document all aspects of patient care.
Aberrant drug-taking behaviors, which are probably more predictive of addiction-related outcomes, are selling prescription drugs; prescription forgery; stealing or borrowing another patient's drugs; injecting an oral formulation; obtaining prescription drugs from nonmedical sources; concurrent abuse of related illicit drugs; multiple episodes of unsanctioned dose escalations; and recurrent prescription losses.
Aberrant drug-taking behaviors, which are probably less predictive of addiction-related outcomes, are aggressive complaining about the need for higher doses; drug hoarding during periods of reduced symptoms; requesting specific drugs; unapproved use of a drug to treat another symptom; obtaining similar drugs from other medical sources; reporting psychic effects not intended by the clinician; and 1 to 2 episodes of unsanctioned dose escalations.
Specific areas requiring clinician documentation include history of medication use, pain complaints, and substance abuse or addiction; screening tool assessments, such as Screener and Opioid Assessment for Patients with Pain (SOAPP) or the Opioid Risk Tool (ORT); pain score/intensity; physical examination; results of diagnostic testing; diagnosis and clinical indication for prescribing opioids; and assumed and/or hypothesized pathology.
The treatment plan should document treatments, both pharmacologic (type of medication, dosage, quantity, and date prescribed) and nonpharmacologic (physical therapy, exercise, behavioral therapy, and/or lifestyle changes as indicated). Treatment goals and anticipated time course should be recorded, as well as compliance measures, such as urine drug screens, pill, or patch counts.
Other essential parts of the medical record are informed consent, including discussion of risks and benefits, and agreement for treatment, which should delineate the patient's responsibilities and clinic policies. Periodic review should include pain score/intensity and perceived analgesia from current medications; physical, occupational, and overall functioning; family and social relationships; mood; sleep patterns; adverse events and their severity; aberrant drug-taking behaviors; medication flow chart; and consultations and referrals as indicated to provide appropriate and comprehensive care.
Because the adverse effects of opioid therapy can usually be predicted, prevented, or treated, concern about adverse effects should not prevent opioid treatment of chronic pain. However, early recognition of adverse effects and aggressive management is an essential component of opioid treatment.
Typical adverse effects of opioids include constipation, nausea, vomiting, sleepiness, cognitive dysfunction, and respiratory distress. Except for constipation, most adverse effects resolve as tolerance develops. Constipation should be managed with use of both a stimulant laxative and stool softener.
When there are neuropsychological adverse effects, direct dose reduction may be helpful. Adding a nonopioid analgesic may facilitate dose reduction. When the opioid dose is carefully titrated, respiratory depression seldom occurs. Tolerance to the respiratory depressant effect usually develops during long-term administration of opioid treatment.
"Primary care physicians are skilled at managing comorbidities in their patients, yet they face a dilemma when it comes to managing chronic pain because the pharmacologic treatment of choice, opioid analgesics, are controlled drugs," the authors write. "Given the privileged nature of their relationship with patients, primary care physicians should feel secure in their responsibility to provide appropriate analgesia for patients with chronic pain. Concerns regarding abuse potential should not impede appropriate medical use of opioids."
Abbott Laboratories funded medical writer Rachelle Weiss, PhD, to assist the authors with manuscript preparation.
Southern Med J. 2007;100:1028-1036.