Opioid guidelines in the management of chronic non-cancer pain

American Society of Interventional Pain Physicians, Paducah, KY 42001, USA.
Pain physician (Impact Factor: 3.54). 02/2006; 9(1):1-39.
Source: PubMed


Opioid abuse has increased at an alarming rate. However, available evidence suggests a wide variance in the use of opioids, as documented by different medical specialties, medical boards, advocacy groups, and the Drug Enforcement Administration (DEA).
The objective of these opioid guidelines by the American Society of Interventional Pain Physicians (ASIPP) is to provide guidance for the use of opioids for the treatment of chronic non-cancer pain, to bring consistency in opioid philosophy among the many diverse groups involved, to improve the treatment of chronic non-cancer pain, and to reduce the incidence of drug diversion.
A policy committee evaluated a systematic review of the available literature regarding opioid use in managing chronic non-cancer pain. This resulted in the formulation of the essentials of guidelines, a series of potential evidence linkages representing conclusions, followed by statements regarding relationships between clinical interventions and outcomes.
Consistent with the Agency for Healthcare Research and Quality (AHRQ) hierarchical and comprehensive standards, the elements of the guideline preparation process included literature searches, literature synthesis, systematic review, consensus evaluation, open forum presentations, formal endorsement by the Board of Directors of the American Society of Interventional Pain Physicians (ASIPP), and blinded peer review. Evidence was designated based on scientific merit as Level I (conclusive), Level II (strong), Level III (moderate), Level IV (limited), or Level V (indeterminate).
After an extensive review and analysis of the literature, the authors utilized two systematic reviews, two narrative reviews, 32 studies included in prior systematic reviews, and 10 additional studies in the synthesis of evidence. The evidence was limited.
These guidelines evaluated the evidence for the use of opioids in the management of chronic non-cancer pain and recommendations for management. These guidelines are based on the best available scientific evidence and do not constitute inflexible treatment recommendations. Because of the changing body of evidence, this document is not intended to be a "standard of care."

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    • "Opioids are often prescribed for chronic pain but their utility is frequently limited by their gastrointestinal (GI) side effects. For instance, constipation is known to occur in 15-90% of patients receiving opiates and is known to have a negative impact on health related quality of life (QOL).1 Whilst the long-term use of opiates in patients with chronic non-cancer pain escalates, evidence suggests that opiates fail to fulfil any of the key outcomes in terms of adequate pain relief, improved QOL or improvements in functional capacity.2,3 "
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    ABSTRACT: The worldwide use of opiates is increasing yet there is little evidence that in long-term, non-cancer patients, they have an efficacious effect on functional outcomes and quality of life measures. Although it seems paradoxical, chronic opiate use may lead to a pro-nociceptive state. Mechanisms for the development of the hyperalgesic state include activation of the opiate bimodal regulatory systems, dynorphin and spinal cord glia. A potential consequence of chronic opiate usage is the development of narcotic bowel syndrome, which is characterized by chronic or intermittent colicky abdominal pain or discomfort that worsens after the narcotic effects of opiates wear off. It is likely that this is an under-recognized diagnosis. We describe here a case of 26-year old female who had visited our institution multiple times with intractable chronic abdominal pain in the context of normal findings on haematological, biochemical, metabolic, endoscopic and radiological investigations. She had been treated with a multitude of opioid agonists with escalating doses. A diagnosis of narcotic bowel syndrome was made. On elective admission her daily analgesic requirements were 150 µg/hr fentanyl, 100 mg oramorph and 400 mg tramadol (equating to 740 mg oral morphine/24 hr). A detoxification regimen was prescribed which included rapid opiate withdrawal couple with the commencement of methadone, lorazepam, clonidine and duloxetine. She was discharged opiate free, with no abdominal pain, 14 days after admission. Clinicians must be aware of narcotic bowel syndrome, which is often erroneously labelled as a functional gastrointestinal disorder, in patients who have been on long-term opiates.
    Journal of neurogastroenterology and motility 01/2013; 19(1):94-8. DOI:10.5056/jnm.2013.19.1.94 · 2.30 Impact Factor
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    • "Although the therapeutic use of the opioids in the management of pain has long been established and opioids may even be underutilized at times (Ballantyne, 2007; Trescot et al., 2006, 2008) there is also growing concern that over the last two decades, there has been a large increase in the prevalence of prescription opioid use disorders (Blanco et al., 2007; Cicero and Inciardi, 2005; Compton and Volkow, 2006; McCabe, 2005; Rigg and Ibanez, 2000; Zacny et al., 2003). It is estimated that the 12-month prevalence of prescription opioid use disorders is 0.30% (Blanco et al., 2007), affecting over one million adults in the US (Grant et al., 2004b). "
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    ABSTRACT: Background: Prescription opioid use disorders are the second most common drug use disorder behind only cannabis use disorders. Despite this, very little is known about the help-seeking behavior among individuals with these disorders. Methods: The sample included respondents of the Wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) with a lifetime diagnosis of prescription drug use disorders (N=623). Unadjusted and adjusted hazard ratios are presented for time to first treatment-seeking by sociodemographic characteristics and comorbid psychiatric disorders. Results: The lifetime cumulative probability of treatment seeking was 42% and the median delay from prescription drug use disorder onset to first treatment was 3.83 years. Having an earlier onset of prescription opioid use disorder and a history of bipolar disorder, major depression disorder, specific phobia and cluster B personality disorders predicted shorter delays to treatment. Conclusions: Although some comorbid psychiatric disorders increase the rate of treatment-seeking and decrease delays to first-treatment contact rates of treatment-seeking for prescription drug use disorder are low, even when compared with rates of treatment for other substance use disorders. Given the high prevalence and adverse consequences of prescription drug use disorder, there is a need to improve detection and treatment of prescription opioid use disorder.
    Drug and alcohol dependence 01/2013; 131(1-2). DOI:10.1016/j.drugalcdep.2012.12.013 · 3.42 Impact Factor
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    • "However, lower median daily doses of diazepam (30–45 mg) have been observed in other studies (Du Pont, 1988; Iguchi et al., 1993). Like heroin users in and out of treatment, patients with chronic pain are often under long-term opioid therapy (American Academy of Pain Medicine, 1997; Ballantyne and Mao, 2003; Trescot et al., 2006). It has been noted that as many as 40% of these individuals develop aberrant patterns of opioid use such as: obtaining opioids from multiple prescribers, forging prescriptions, stealing opioids, and intranasal or intravenous use of oral opioids (Passik et al., 2006, for a review see Ballantyne and LaForge, 2007; Fishbain et al., 1992). "
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    ABSTRACT: This paper reviews studies examining the pharmacological interactions and epidemiology of the combined use of opioids and benzodiazepines (BZDs). A search of English language publications from 1970 to 2012 was conducted using PubMed and PsycINFO(®). Our search found approximately 200 articles appropriate for inclusion in this paper. While numerous reports indicate that the co-abuse of opioids and BZDs is ubiquitous around the world, the reasons for the co-abuse of these medications are not entirely clear. Though the possibility remains that opioid abusers are using BZDs therapeutically to self-medicate anxiety, mania or insomnia, the data reviewed in this paper suggest that BZD use is primarily recreational. For example, co-users report seeking BZD prescriptions for the purpose of enhancing opioid intoxication or "high," and use doses that exceed the therapeutic range. Since there are few clinical studies investigating the pharmacological interaction and abuse liability of their combined use, this hypothesis has not been extensively evaluated in clinical settings. As such, our analysis encourages further systematic investigation of BZD abuse among opioid abusers. The co-abuse of BZDs and opioids is substantial and has negative consequences for general health, overdose lethality, and treatment outcome. Physicians should address this important and underappreciated problem with more cautious prescribing practices, and increased vigilance for abusive patterns of use.
    Drug and alcohol dependence 08/2012; 125(1-2):8-18. DOI:10.1016/j.drugalcdep.2012.07.004 · 3.42 Impact Factor
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