PERSECTIVES ON OPIOID TREATMENT
OF CHRONIC PAIN
Jane C Ballantyne MD FRCA
University of Washington School of Medicine
Seattle, WA
USA
The arrangement was not to prove a very satisfactory one:
the Queen was to find Helena (her daughter) - who, like to so
many of her contemporaries, became addicted to laudanum 'difficult to live with'.
Christopher Hibbert in Queen Victoria, a Personal History, Da Capo press 2001, p 393
“I’d rather be in pain than
have anyone think I’m an
addict”.
From Kathleen Foley, quoting one of her
patients. This clinical anecdote captures
the reality of the under treatment of
pain, which is one of the serious,
unintended consequences of the war on
drugs.
The moral case
Opioids should not be withheld from patients with chronic pain
because patients denied opioid suffer needlessly
The safety case
Addiction rates during chronic pain treatment are very low
The case for long-acting opioids
Long-acting opioids provide better, more stable and continuous pain
relief and are preferred especially in patients at risk of abuse, because
the steady state removes the focus on getting the next dose
Brennan F, Carr DB, Cousins M. Pain management: a fundamental human right. Anesth Analg.
2007;105(1):205-221.
Expanded Treatment
1997 Three societies issues guidelines:
- “expanded use of opioids”
- “more compassionate care”
By 2008
- opioids are most prescribed medications
- Pain Management Clinics + 350%
- Methadone
+1,000%
- Oxycodone
+ 878%
Sources: Automation of Reports and Consolidated Orders System
•Chronic pain rapidly acquired disease status
•Pain management became a specialty in its own right
•Pain management was rarely included in medical school
curricula
•Physicians at the front line learned then through postgraduate education (often drug-company sponsored) and
through advertising
What has been learned from the widespread
adoption of chronic opioid treatment in the
US?
1) Analgesia from opioids deteriorates over time, and
patients develop opioid refractoriness
2) Addiction is a far greater problem than once
thought, both for opioid treated pain patients and for
those around them
•increasingly patients present with severe pain despite
opioid treatment
(Mao ’02, Mercadante et al ’04)
•some patients improve when taken off opioids
(Schofferman ’93, Harden ’02)
•acute pain may become refractory to opioids in
chronic users
(Mitra & Sinatra ’04, Wilder-Smith & Arendt-Nielsen ’06, Angst & Clark ’06)
Mechanisms for deterioration in analgesia
over time
•Pharmacological tolerance
•Opioid-induced hyperalgesia
•Withdrawal
•Psychologic factors