Who gets high-dose opioid therapy for chronic non-cancer pain?

Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington, 1959 NE Pacific St Seattle, WA 98195, USA.
Pain (Impact Factor: 5.21). 12/2010; 151(3):567-8. DOI: 10.1016/j.pain.2010.08.036
Source: PubMed
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    ABSTRACT: The prescribing of opioid medicines is increasing progressively despite a substantial body of literature identifying potential limitations and harms of therapy. Production and dissemination of best practice guidance in relation to prescribing do not yet seem to have an impact on this trend. This article highlights updated concerns about and unanswered questions in relation to opioid treatment to provide focus for further scrutiny and evaluation of opioid treatment for pain. The literature cited in this paper confirms that opioid prescribing is prevalent despite an established evidence base spanning a decade that indicates that efficacy of opioids in long-term pain management remains uncertain and that harms of therapy are well defined. In particular, problems with treatment are more likely to occur when high doses are used and in certain patient populations and many recent high-quality studies highlight these problems. Although much is to be learned regarding clinical decision making, it is clear that current prescribing activity does not reflect the existing knowledge base. Authors are unanimously agreed that the literature answers some important questions about opioid therapy but there are substantial knowledge gaps, particularly in relation to benefits and harms of long-term therapy in day-to-day clinical practice. Evidence-derived guidance clearly identifies common and important pitfalls in relation to opioid use but promotion of adherence to guidance remains a substantial challenge.
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    ABSTRACT: There is a bidirectional relationship between depression and chronic medical disorders. The adverse health risk behaviors and psychobiological changes associated with depression increase the risk for chronic medical disorders, and biological changes and complications associated with chronic medical disorders may precipitate depressive episodes. Comorbid depression is associated with increased medical symptom burden, functional impairment, medical costs, poor adherence to self-care regimens, and increased risk of morbidity and mortality in patients with chronic medical disorders. Depression may worsen the course of medical disorders because of its effect on proinflammatory factors, hypothalamic-pituitary axis, autonomic nervous system, and metabolic factors, in addition to being associated with a higher risk of obesity, sedentary lifestyle, smoking, and poor adherence to medical regimens. Both evidence-based psychotherapies and antidepressant medication are efficacious treatments for depression. Collaborative depression care has been shown to be an effective way to deliver these treatments to large primary care populations with depression and chronic medical illness.
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    ABSTRACT: Pain is one of the most common reasons that patients seek treatment from health care professionals, often their primary care providers. One tool for treating pain is opioid therapy, and opioid prescriptions have increased dramatically in recent years in the United States. This article will review recent research about opioids that is most relevant to treating chronic pain in the context of a typical primary care practice. It will focus on four key practices that providers can engage in before and during the course of opioid therapy that we believe will enhance the likelihood that opioids, when used, are an effective tool for pain management: avoiding sole reliance on opioids; using adequate opioid doses to address pain; mitigating the risk of opioid misuse by patients; and fostering collaborative relationships for treating complex patients.
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