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Conrad Notes
a timely medical meeting newsletter
OPIOIDS IN CHRONIC NONMALIGNANT PAIN
R. Portenoy, MD, Memorial Sloan Kettering Cancer Center (MSKCC), New York City, proposes reappraising the traditional prescribing of opioid drugs. This recommendation is based on a review of the literature on substance abuse and chronic pain. Careful patient evaluation before and during treatment of nonmalignant pain with opioids is highly recommended.
Traditional views in treating nonmalignant pain Many clinicians think that opioids are inappropriate therapy for chronic nonmalignant pain. Reasons for such negative views include:

  • addiction potential

  • frequent side effects

  • tolerance with long term use

  • many nonresponsive pains

  • chronic therapy contributes to disability

Clinical experience, combined with a critical reevaluation of these concerns, suggests the existence of a subpopulation of patients who could benefit from opioids (J Pain Symptom Manage 1996;11:203-217).

Addiction potential of opioids Opioids possess the potential for producing addiction; however, pain specialists find very few cancer patients becoming addicted to opioids. Physical dependence is not the same as addiction. The definition for addiction needs to include loss of control, compulsive use, and continued use in spite of harm.

Epidemiologic studies show a low risk of addiction to opioids taken by patients with no history of substance abuse. For example, the 1980 survey by the Boston Collaborative Group found only 4/11,882 (0.03%) patients became addicted to an opioid. This survey included patients given an opioid for at least four months in a hospital setting. The Perry and Heidrich survey on 10,000 burn center patients, treated with opioids, failed to identify any patients as substance abusers. Nevertheless, additional studies would help clarify the risk for addiction to patients with chronic nonmalignant pain treated with opioids.

Frequency of side effects Side effects occur frequently in opioid-treated cancer patients but none of these cause major organ dysfunction. The side effects appear early and patients quickly develop tolerance to them. Since social and situational factors can influence opioid effects, the need continues for information on drug-related behaviors.
Analgesic tolerance Therapeutic resistance is not a characteristic of opioids. Absence of pain relief to increasing doses is very uncommon.
Nonresponsive pains Portenoy's review of the literature found controlled trials and anecdotal reports supporting the use of opioids for chronic nonmalignant pain. For example, the randomized, cross-over, placebo-controlled study of Moulin et al (Lancet 1996;347:143-7) showed nonneuropathic musculoskeletal pain significantly lessened by controlled-release morphine sulfate. Published anecdotal reports on over 1,000 patients support the clinical effectiveness of opioids in nonmalignant pain. However, additional controlled studies are needed to define the subpopulation of nonmalignant pain patients more likely to benefit from opioid analgesics. /TD>
Is chronic opioid therapy disabling? Portenoy recommends keeping careful patient records as progress notes as an alerting device during long-term treatment. Pain severity needs to be measured minimally on a scale of mild, moderate and severe. Does the patient experience side effects such as sedation, constipation, or cognitive impairment? What is the patient's physical and psychosocial status? Is there any drug-related aberrant behavior?

M. J. Kreek, MD, Rockefeller University, New York City, asked Portenoy to recommend a course of action when encountering aberrant or addictive behavior during treatment. Portenoy, an expert in pain management, enlists a specialist in addiction disorders to jointly assess the patient's behavior and develop a treatment regimen.

For professional correspondence, please contact Dr. Portenoy at: portenor@mskmail.mskcc.org

Eugene A. Conrad

Presented at the Conference on Pain Management and Chemical Dependency on 22 Nov 1996
CONRAD NOTES © All Rights Reserved December 1996
Eugene A. Conrad, PhD, MPH / ISSN 1078 / posted on 1-Feb-1997

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