AnesthesiaWeb - Lit Reviews- Opioid Substitution to Improve the Effectiveness of Chronic Noncancer Pain Control

July 2000

Opioid Substitution to Improve the Effectiveness of Chronic Noncancer Pain Control: A Chart Review
Quang-Cantegrel ND, Wallace MS, Magnuson SK. Anesth Analg 2000; 90:933-937

[see abstract below]

Commentary by Richard W. Rosenquist, M.D.

The authors of this study evaluated the efficacy and tolerability of opioids in long-term management of chronic noncancer pain. There is no question that the management of chronic noncancer pain in patients is a challenge. The use of opiates for the management of long-term chronic noncancer pain remains quite controversial. This is in part due to the issues of addiction and tolerance and in part due to the variable success rates in using these medications to treat chronic nonmalignant pain. There is evidence to suggest that opioids can improve the level of analgesia and quality of life in some patients. The goal of pain treatment in patients with chronic pain is not only to provide pain relief, but also recovery of physical and social function and ideally return to work. As a result, physicians and patients are challenged with finding a balance between the adverse side effects of these medications and the benefits of pain relief. Frequently patients are required to trial a variety of opiate therapies before deciding if the use of long-term opiates is feasible and whether or not the benefits are worth the costs.

This retrospective chart review included 86 outpatients with chronic noncancer pain seen at the University of California San Diego Pain Clinic. These patients were seen between 1994 and 1998, and were treated with long-acting opiates. For each patient, the number of different opioids used and the efficacy and tolerability of each opioid prescribed was noted. During a mean follow-up of 8.8 � 6.3 months, the number of opioids used by each patient was 2.3 � 1.4. Patient diagnoses included back pain, neuropathy, joint pain, visceral pain, reflex sympathetic dystrophy, headache and fibromyalgia.

The authors found that the first opioid prescribed was effective for 36% of patients, and was stopped because of side effects in 30% and for ineffectiveness in 34%. Of the remaining patients, the second opioid prescribed after the failure of the first was effective in 31%, the third in 40%, the fourth in 56%, and the fifth in 14%. There was one case of addiction and no cases of tolerance.

The authors then concluded that, if it is necessary to change the opioid prescription because of intolerable side effects or ineffectiveness, the cumulative percentage of efficacy increases with each new opioid tested. Failure of one opioid cannot predict the patient's response to another.

These investigators have outlined in a well-organized fashion one of the realities encountered by practitioners of Pain Medicine. That is, the treatment of pain is a highly individual process with respect to the types of treatment, medical management and interventions that are effective and produce a successful outcome. It is difficult for patients and for physicians to accept the need for a trial and error process in developing a successful treatment regimen. Patients are often frustrated with the long term problem and would like a rapid solution. The evidence in this paper suggests that it remains extremely important to sit down with the patient at the beginning and outline to them the difficulties of treating chronic noncancer pain with opioids and the need for methodical drug trials to develop a successful treatment regimen. This paper provides evidence that this difficult process is necessary and common, and provides useful percentages in sitting down to discuss the realities of treating chronic noncancer pain with opiates.