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n History
of Opioids
Although there is
universal recognition of the potent
analgesic effects of opioids, many
physicians are reluctant to employ them due
to the risk of addiction. Over the last few
decades, the benefits of opioid use in the
acute post-operative period and in cancer
patients has become evident. Despite that,
the controversy between lay people,
regulatory authorities, and physicians
remains regarding the use of opioid
analgesics for chronic non-cancer pain.
While the debate stays open, millions of
patients with acute and chronic pain suffer
the consequences. To better understand the
cultural and regulatory barriers that
surround the medical use of opioids, it is
instructive to analyze the historical
context about their use and abuse.
n Opioids:
Types and Uses
There are many types
of opioids and they are classified in many
ways. For example: 1) Natural vs.
semi-synthetic vs. synthetic. 2) Strong vs.
weak. 3) Duration of action- a. short vs.
medium; b. immediate release vs. controlled
release. 4) Analgesic vs. nonanalgesic. 5)
By federal schedule (CI-CV). 6) By receptor
affinity. 7) Legal vs. illegal. 8) Agonist
vs. partial agonist vs. antagonist. There
are many uses for opioids. The major focus
here is, of course, on analgesia. But there
are other, often fascinating, uses which
will be covered: anesthesia, antitussive,
antidiarrheal, antispasmodic, drug abuse,
opioid maintenance treatment, opioid
detoxification, vasodilatation/smooth
muscle relaxation, and even antiterror.
n Risk
Management and Related Medico-Legal
Issues
n with the Practice of Chronic
Opioid Therapy
Risk management and
related micro-legal issues are reviewed with
respect to clinicians who undertake chronic
opioid therapy in their practice. Risk
factors are discussed with reference to typical
malpractice claims, medical board
complaints, and reports in medico-legal
literature. Specific issues include
guideline and Model Pain Policies
implementation, scope of practice, record
keeping/documentation, patient abandonment,
communication with co-treating clinicians,
and particular risks within solo versus
group practice. The relative risk of
undertaking chronic opioid therapy is
contrasted to risks inherent in other
pharmacotherapy or interventional
treatments.
n Rotation
of Opioids
Escalating opioid
requirements can be a consequence of either
progression of disease or tolerance. There
is increasing awareness among pain
specialists that there may be a ceiling
effect on the opioid dosing above which
hyperalgesia, sedation, cognitive
dysfunction, myoclonus or other
side-effects may limit further upward
titration. Opioid rotation takes advantage
of incomplete opioid cross-tolerance which
implies that an equianalgesic dose of a
different opioid—one to which the
patient has not been exposed before—will
be much lower than expected. This may result
in a 40% reduction in dosage while
maintaining the same or better analgesia.
Providers can use opioid rotation to reduce
side-effects or improve efficacy in opioid
tolerant individuals.
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n Judicious
Screening: Psychosocial Issues with
n Chronic
Opioid Therapy
Assessment of chronic
pain is discussed with a focus on
psychosocial
evaluation and screening. Screening issues
are addressed with respect to chronic
opioid therapy with commentary on
behavioral strategies intended to maximize
adherence to the medical treatment regimen.
The integration of nonpharmacologic
strategies into the treatment regimen is
discussed with a brief review of cognitive
and relaxation interventions.
Evidence-based interdisciplinary treatment
is emphasized with additional discussion on
barriers to effective treatment.
n Interventional
Techniques Used in Pain Management
There are various
interventional techniques that can be used
in pain management. One important
consideration is the use of image guidance
in the performance of said interventional
techniques and differential diagnosis
between certain types
of pain. Back,
neck, and head pain all have common causes.
Possible interventional techniques to treat
these three conditions include sacroiliac
injection, facet/medial branch injection, sympathetic
blocks, discography, radiofrequency, IDET,
percutaneous disc decompression,
vertebroplasty, Botox® injection, and implantables
(nerve stimulators and intrathecal pumps). The
indications, contraindications, and
possible side effects of these techniques
will be discussed.
n Identification
and Treatment of Opioid Dependence
Opioid dependence is
a brain disease which will affect a certain
percentage of patients treated with opioid
analgesics for pain. It is crucial for
physicians treating pain with opioids to be
able to identify and treat these patients
in a timely and effective manner. In 2002,
the Drug Addiction Treatment Act gave all
physicians (including pain management,
family practice and internal medicine
practitioners) the legal right to treat
their patients for opioid dependence in the
privacy of their own office. This
introductory presentation will cover the
following topics: overview of opioid
dependence, in-office treatment options for
opioid dependence, opioid dependence in
chronic and acute pain patients, patient
assessment and treatment/referral process,
and available clinical tools.
n Urine
Drug Testing: Which Patient, Which Drug,
Why
Opioid toxicology in
various disease states will be discussed,
along with the issue of rotation, the use
of adjunctive medications, and how to taper
and increase dosing in a safe manner. The
treatment of side effects will be
considered. Drug screening will cover use
and misuse of opioids and what testing is
most helpful. Urine testing, although
not totally accurate, is a quick,
practical, and cost-effective way of making
sure which patients are or are not taking
medications and to protect physician and
patient from the problem of diversion.
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