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 OPIOID Rx & Safety [General]
This section focuses on dispelling the myths surrounding opioid agonists. Clinical guidance is provided for more effective application and prescribing of these vital pain medications, with a special emphasis on safety and risk management issues to prevent misuse and adverse events.
NOTE: All URL links listed below were valid at the time of posting; however, the Internet is constantly changing and some linked sites may move or become inactive with time. Please notify us of any broken links at: Info@Pain-Topics.org
 Also of interest, Opioid Therapy & Safety Guidelines <Click Here>
 Also see the following articles in the Current Comments section...
 Patients Who Require Ultra-High Opioid Doses
By: Schneider J, Anderson A, Tennant F. Patients who require ultra-high opioid doses. PPM. 2009(Sep);9(7):10+.
 PDF available at: http://pain-topics.org/pdf/PPM_Sept09_UltraHighOpioid.pdf
Controversy still exists about the long-term prescribing of opioids for chronic noncancer pain (CNCP) conditions, and particularly regarding the safety and effectiveness of higher opioid doses. Yet, there appears to be a subset of patients with CNCP who require and thrive on ultra-high morphine-equivalent opioid doses exceeding 1,000 mg/day — demonstrating that what some practitioners might consider as being way too much opioid is just the right amount for certain patients. Full article download courtesy of Practical Pain Management. For more information on this journal [click here]. Access checked 9/25/09.
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Opioid Metabolism
By: Howard S. Smith, MD. Mayo Clin. Proc. 2009(Jul);84(7):613-624.
 See document at: http://www.mayoclinicproceedings.com/content/84/7/613.full
 This excellent review, of interest for all healthcare providers, describes the basics of opioid analgesic metabolism and the factors influencing it. Recommendations are provided for addressing metabolic issues that may compromise effective pain management. Of critical importance, individual patients differ in their response to specific opioid analgesics and they may require trials of several opioids before finding an agent that provides effective analgesia with acceptable tolerability. Access checked 7/24/09.
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A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain: Tailoring Therapy to Meet Patient Needs
By: Charles E. Argoff, MD and Daniel I. Silvershein, MD. Mayo Clin. Proc. 2009(Jul);84(7):602-612.
See document at: http://www.mayoclinicproceedings.com/content/84/7/602.full
When considering opioid analgesics for the management of chronic noncancer pain (CNCP) prescribers need to understand the pharmacokinetics and pharmacodynamics of the various opioid formulations as they relate to the temporal characteristics of the patient's pain. This article aids in deciding whether to prescribe a short-acting opioid with a relatively quick onset of action and short duration of analgesic activity, a long-acting opioid with a longer duration of analgesic action but a potentially longer onset of action, or both. Studies suggest that both types of opioids are effective for most CNCP conditions; however, opioid therapy should be tailored to the pain state and the individual patient. Access checked 7/24/09.
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Opioid Pharmacology
By: Andrea M. Trescot, MD, et al. Pain Physician; 2008(March);11:S133-S153 (26pp).
PDF available at: http://www.painphysicianjournal.com/2008/april/2008;11;S133-S153.pdf
 This document provides an excellent clinical overview of opioid history, structure, receptors, and pharmacokinetics. A number of opioid analgesics available for clinical use are covered, including morphine, codeine, hydrocodone, hydromorphone, oxycodone, fentanyl, methadone, meperidine, propoxyphene, buprenorphine, levorphanol, and tramadol. The 4 chemical classes of opioids are described. Distinctions are made between opioid agonists, partial agonists, agonist-antagonists, as well as pure antagonists.
The authors examine the structure, chemistry, and metabolism of opioids to help healthcare providers better understand the side effects, drug interactions, and individual responses of patients receiving opioids. Advantages and disadvantages of the various opioids in the management of pain are discussed. Many helpful tables and charts are included. Access checked 6/15/09.
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A Practical Guide for Prescribing Controlled Substances [Opioid Safety Tips™]
By: Nathaniel Katz, MD, MS, et al. From: PainBalance.org, 2007.
Online document available at: http://www.csrxtips.com/
 This industry-sponsored, noncommercial project provides important guidance for opioid prescribers and pharmacists, as well as suggestions for educating patients. Each of the 50 Opioid Safety Tips™ is brief, to-the-point, and includes a photographic reminder plus brief explanatory text. Most tips are based on commonsense best practices – eg, “Do not prescribe controlled substances outside the scope of your usual professional practice” – but nonetheless provide an excellent review and reference for even the most experienced healthcare provider. Readers can also submit their own tips for inclusion in future editions of the Guide. Access checked 10/7/08.
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Safe Oral Equianalgesic Opioid Dosing for Patients With Moderate-to-Severe Pain
 By: Samuel M. Galvagno, Jr, DO, et al. Resident & Staff Physician; 2007(April);53(4).
HTML article available at: http://www.residentandstaff.com/issues/articles/2007-04_06.asp
The authors clarify misunderstandings about the use of short-acting and sustained-release opioids, as well as equianalgesic dosing when switching patients from one to the other. Definitions of pertinent concepts are provided, and strategies for parenteral-to-oral conversion are outlined, as well as the rationale for avoiding potentially hazardous opioids. A patient education guide for methadone use is included. Accessed 2/5/08.
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Opioid Safety in Patients With Renal or Hepatic Dysfunction
By: Sarah J. Johnson, PharmD; from Pain Treatment Topics, Updated November 30, 2007.
PDF available here for download: Opioids-Renal-Hepatic-Dysfunction.pdf (225 KB, 9 pp)
 Patients with kidney or liver disorders often need opioid analgesics for effective pain relief. However, there is a risk of opioid overdose or other adverse events in these patients due to the possibility of altered drug pharmacokinetics and toxic accumulation of the parent opioid and/or its metabolites. This evidence-based report exclusively from Pain Treatment Topics provides a comprehensive list of clinical cautions and dosing recommendations relating to various opioids.
Prescribing Pointers in the Report: In renal or hepatic dysfunction, usual or adjusted doses may be appropriate for certain opioids, including morphine, hydromorphone, hydrocodone. Other opioids should be avoided at all times – including codeine, meperidine, and propoxyphene – and oxycodone should not be used in dialysis patients. Methadone and fentanyl are generally not first-line therapies, although they can be carefully used in patients with renal dysfunction or on dialysis, but methadone is not advised in severe liver failure. For most patients with kidney or liver disease, either morphine or hydromorphone could be a good starting therapy if an opioid agent is appropriate for pain relief.
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Opioid Analgesics for Chronic Pain
By: Mary Lou Bossio, NP; from Advance for Physician Assistants; 2007.
HTML online at: http://physician-assistant.advanceweb.com/Common/editorial/editorial.aspx?CC=84278
 An appreciation of chronic pain and its prevalence, along with a thorough understanding of provider responsibilities, patient rights, and the appropriateness of opioid analgesics for this population are needed. Such knowledge provides a foundation for evaluating chronic pain and developing an individualized management plan.
In this brief paper, the author emphasizes that, when opioids are used, prepare for both expected and unexpected results. The goal for clinicians in all settings is to responsibly offer opioid analgesic therapy to patients for whom it is indicated and justified. Additionally, healthcare providers must ensure that opioids are not being used for nonmedical reasons. The authors note, "We can try to minimize the risk of deception and provide pain relief for some, or we can accept the risk and ensure pain relief for all."
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Managing Opioid-Induced Constipation in Ambulatory-Care Patients
By: Clyde R. Goodheart, MD, MBA, MS; Stewart B. Leavitt, MA, PhD; from Pain Treatment Topics, August 2006.
PDF available here for download: Managing_Opioid-Induced_Constipation.pdf (180 KB; 9 pp)
 Constipation is a frequent side effect of opioid therapy since these agents decrease peristaltic activity in the gastrointestinal tract. Because of the mechanisms involved in opioid-induced constipation, some treatments that may be applicable for common, functional constipation are inappropriate for ambulatory-care patients prescribed opioid analgesics.
The distress of constipation in these patients may add to the discomfort already present from pain, and they might decrease or discontinue opioid therapy to avoid constipation. So, motivating such patients to comply with their opioid regimen also requires a special approach for managing constipation.
Certain popular beliefs about treating constipation have little or no evidence to support them. For example, adding fluids or fiber to the diet, and increasing activity, may be unhelpful in patients with opioid-induced constipation. In most cases, laxative therapy will be needed for prevention or for treatment of existing constipation.
Also see: Constipation… from Consumer Reports Best Buy Drugs, December 2008.
http://www.consumerreports.org/health/best-buy-drugs/constipation.htm
 This document discusses the various causes of constipation and the full range of treatment options, including their costs. For constipation triggered by an opioid drug, over-the-counter polyethylene glycol is recommended by Consumer Reports as effective and economical laxative therapy.
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Overview of Oral Modified-Release Opioid Products for the Management of Chronic Pain
By: Calene M. Amabile, PharmD, BCPS, and Bill J. Bowman, BSPharm, PhD. Medscape, Ann Pharmacother; 2006;40(7).
Available online at: http://www.medscape.com/viewarticle/542574
 Oral modified-release opioid products have enabled patients to better maintain pain control via convenient dosing intervals and sustained blood concentrations, which also may decrease side effects. The differences between available oral modified-release products involve their half-life, cost, and formulation. Modified-release delivery systems incorporate what has been termed extended-release (ER), controlled-release (CR), or sustained-release (SR) mechanisms. While specific definitions of these are sometimes non-specific, there are differences in modified-release technologies that can impact patient response to individual products. This paper describes those differences and provides useful information for product selection. Accessed 2/5/08.
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Opioid Tapering: Safely Discontinuing Opioid Analgesics
By: Lee A. Kral, PharmD, BCPS; from Pain Treatment Topics, March 2006.
PDF available here for download: Safely_Tapering_Opioids.pdf (140 KB; 7 pp)
 There are many reasons for considering opioid analgesic tapering, both from healthcare-provider and patient perspectives. Whereas, guidance for starting opioid analgesics can be obtained from product package inserts and reference sources, it is much more difficult to find reliable information about switching or stopping these medications. Some practitioners have their own protocols for managing conversions or tapers; although, there is no single strategy that can be applied to all patients and each situation must be handled on an individual basis
This paper discusses the many factors to consider when discontinuing opioid analgesics, and it presents specific and practical clinical guidance for establishing protocols that maximize patient safety and comfort during the process. Important advice for patients regarding emergency tapering – such as following natural disasters or other crises when medication is inaccessible – also is provided.
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Opioids for Chronic Nonterminal Pain
By: Jane C. Ballantyne, MD, FRCA; from Medscape; South Med J, 99(11); 2006.
HTML article available online at: http://www.medscape.com/viewarticle/549294
 This article reviews the evidence for and against chronic opioid therapy. Concerns have arisen about loss of efficacy with prolonged use, possibly related to tolerance or opioid-induced hyperalgesia, and these mechanisms are discussed. It is clear from current evidence that many patients abandon chronic opioid therapy because of the unacceptability of side effects. There are also concerns about toxicity, especially when opioids are used in high doses for prolonged periods, related to hormonal and immune function.
The issue of addiction during opioid treatment of chronic pain is also explored. Opioid treatment of pain has been, and remains, severely hampered because of actual and legal constraints related to addiction risk. A structured goal-directed approach to chronic opioid treatment is suggested, which aims to select and monitor patients carefully, and wean therapy if treatment goals are not reached.
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VA/DoD Clinical Practice Guideline for the Management of Opioid Therapy for Chronic Pain
From: Department of Veterans Affairs, Department of Defense; 2003.
PDF available here for download: VA_OpioidsChronicPain_Guide.pdf (1.82 MB, 111 pp)
For updated versions of this same Guideline click HERE.
 Citing the high prevalence and inadequate treatment of chronic pain, the U.S. Department of Veterans Affairs (VA) identified pain management as a priority. In partnership with the Department of Defense (DoD), a panel of experts used an evidence-based approach focusing on chronic opioid therapy (lasting for more than one month). Comprehensively, the guideline addresses pain assessment, therapy indications and contraindications, and patient education. Recommendations and algorithms for all 3 phases of opioid management are presented: 1) initiation phase, 2) titration, and 3) maintenance. Assessments of efficacy, nonadherence, adverse effects, and followup are explored.
As a companion to this document, also see...
Opioid Assessment & Treatment Pocket Guide
PDF available here for download: VA_OpioidPocket_Guide.pdf (233 KB, 2 pp)
Opioid Medications [Dosing] Pocket Guide
PDF available here for download: VA_OpioidDosing_Guide.pdf (169 KB, 2 pp)
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Opioid/Medication Safety Information for Your Patients....
 These Patient Resources are for the benefit of healthcare providers to make available for their patients, as appropriate. They have been reviewed by Pain Treatment Topics staff; however, professional discretion in their distribution and application is advised.
- Proper & Safe Disposal of Prescription Drugs
- Facts About Safely Using Opioids in General
- Guidance on Safely Using Methadone or Oxycodone
- Facts About Prescription Drug Abuse
- Buying Prescription Medicine Online: A Consumer Safety Guide
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Pain Treatment Topics and its associates do not endorse any medications, products, services, or treatments described, mentioned, or discussed in any of the resources in this section. Nor are any representations made concerning efficacy, appropriateness, or suitability of any such medications, products, services, or treatments for particular patients.
In view of the possibility of human error or advances in medical knowledge, Pain Treatment Topics and its associates do not warrant the information contained in the above contents is in every respect accurate or complete, and they are not responsible nor liable for any errors or omissions made by the original sources or for results obtained from the use of this information. |
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