Access to Opioids: a Global Pain Management Crisis

ABSTRACT

The lack of availability of opioids in many countries has created a pain management crisis. Because the Single Convention on Narcotic Drugs requires governments to report annual opioid statistics, there is a need for methods to calculate individual nations’ opioid needs. Ways to address this need are discussed.     

Opioids Versus Physical Therapy for Management of Chronic Back Pain

Chronic low back pain (CLBP) is a common disabling disorder managed by a variety of interventions. The purpose of this article was to review the literature and critique the evidence to determine if opioid analgesics improved patient outcomes compared with physical therapy. No research was found that directly compared the efficacy of opioid analgesics with physical therapy. Although the evidence supports the use of physical therapy in chronic back pain, the study results are conflicting regarding the usefulness of opioid analgesics in CLBP management. More research involving the efficacy of opioid analgesic in treating CLBP is needed.     

The Role of Opioids in Cancer Pain Management

Abstract:   Opioids remain an important cornerstone in the treatment of cancer pain. Effective analgesia is obtained in the majority of cancer pain patients with the application of fairly straightforward algorithms using opioids as the main therapy. Many rational treatment algorithms exist. In this tutorial we will describe the role of opioids in the treatment of cancer pain, including a brief overview of cancer pain syndromes, essential aspects of opioid therapy, opioid pharmacology, opioid rotation, properties of the individual opioids, and management of common side effects of opioids.     

Guideline for Prescribing Opioids for Chronic Pain

Improving the way opioids are prescribed through clinical practice guidelines can ensure patients have access to safer, more effective chronic pain treatment while reducing the number of people who misuse, abuse, or overdose from these drugs. The Centers for Disease Control and Prevention (CDC) developed and published the Guideline for Prescribing Opioids for Chronic Pain to provide recommendations for the prescribing of opioid pain medication for patients 18 and older in primary care settings. Recommendations focus on the use of opioids in treating chronic pain (pain lasting longer than 3 months or past the time of normal tissue healing) outside of active cancer treatment, palliative care, and end-of-life care.     

Pain and Opioids: Call for Policy Action

Opioids were once the cornerstone in treating severe disabling pain and are now known to underlie an epidemic of substance use disorders and overdose deaths. Nurse practitioners are in key positions to influence opioid and pain management policy. As clinicians in primary care and specialty settings, nurse practitioners frequently encounter patients in pain. A white paper developed through the Nurse Practitioner Healthcare Foundation titled Managing Chronic Pain with Opioids: A Call for Change 2017 offers a multifaceted approach to pain management and provides timely recommendations to move policies and practices forward. Key recommendations from the white paper are highlighted.     

Examining Influences on the Availability of and Access to Opioids for Pain Management and Palliative Care

ABSTRACT

This commentary relates to the recently published essay in PLOS Medicine, entitled “Untreated Pain, Narcotics Regulation, and Global Health Ideologies.” That essay describes regulatory and other systemic barriers preventing the accessibility of opioid analgesics and contributing to patients not receiving adequate pain relief. Four main points highlighted in the essay are discussed in this commentary: (1) the role of international treaties in medication availability; (2) the role of the International Narcotics Control Board in medication availability; (3) the role of regulatory policy in treating pain; and (4) the role of opioid analgesics in treating pain. Recent authoritative statements and activities suggest a strengthened infrastructure within which governments currently can work to improve the availability of controlled medicines to enhance patient pain and palliative care services.     

Overdose Risk with Opioids for Chronic Noncancer Pain

ABSTRACT

Timely and important studies are reviewed and commentaries provided by leading palliative care clinicians. Clinical scenarios, symptoms, interventions, and treatment-related adverse events addressed in this issue are overdose risk with opioids in chronic pain; pain in the primary care setting; methadone products and risk of QT prolongation; zolendronic acid and circulating cancer cells; statins and deep venous thrombosis; and treatment for cancer-associated anorexia-cachexia syndrome.     

The White Paper on Opioids and Pain

This document was developed by a group of over two dozen pain clinicians and investigators from Austria, Belgium, Denmark, France, Germany Ireland, Israel, Italy, The Netherlands, Norway, Poland, Portugal. Spain, Sweden, Switzerland and the United Kingdom and funded by an educational grant form Mundipharma International, Limited. The stated aim of the White Paper is to identify inequalities in government policies towards opioids that contribute to inadequate treatment of pain. It calls for their replacement with policies that will support doctors and patients in their efforts to relieve pain.     

Nurses’ Knowledge about Pain Management with Opioids for Dying Patients United Kingdom Nursing Perspective

ABSTRACT

A discussion is presented on nurses’ knowledge and responsibilities in opioid management of pain in advanced disease patients. Documented deficiencies in some nurses’ knowledge are described. A perspective by a clinical nurse specialist also is presented.     

Oral Ketamine for Sickle Cell Crisis Pain Refractory to Opioids

ABSTRACT

There is literature demonstrating that the N-methyl-d-aspartate (NMDA) receptor antagonist ketamine has analgesic properties that can be used as an adjuvant to opiates for pain relief in multiple various conditions and pain states. However, there is a lack of published information on ketamine used in persons with sickle cell disease in acute pain crises. The Virginia Commonwealth University Palliative Care team was consulted on a 38-year-old African American female with sickle cell thalassemia in severe acute pain crisis overlying chronic pain related to her disease. Pain control was unable to be achieved with escalating doses of opiates and other adjuvant medications. The patient responded well to an intravenous test dose of ketamine and was subsequently placed on an oral regimen of ketamine in addition to opiates. In the 24-hour period following ketamine initiation, the patient's pain was able to be controlled on decreased amounts of opiates. She was eventually transitioned to an oral opiate and ketamine regimen, which allowed her to be discharged home with pain levels close to her baseline and the ability to function and perform all activities of daily living.     

Interpreting the Effectiveness of Opioids and Pregabalin for Pain Severity,Pain Interference,and Fatigue in Fibromyalgia Patients

Objective

To evaluate the effectiveness of opioids and/or pregabalin on patient‐reported outcomes among fibromyalgia (FM) patients based on levels of improvement.

Methods

A total of 1,421 FM patients were identified, with 3,082 observational periods of opioids with or without pregabalin use between April 2008 and February 2015. Patients were categorized by opioids, and pregabalin with and without opioids; opioids were designated by morphine equivalent dose (MED) of ≤ 20 (low MED), > 20 to < 100 (moderate MED), ≥ 100 (high MED), and pregabalin doses of ≤ 150 mg, 151 to 300 mg, and 301 to 450 mg. Proportions of patients meeting clinically relevant thresholds of ≥ 30% and ≥ 50% improvement for pain interference (ability to enjoy life; activity; mood; relationships; sleep), pain severity, and fatigue were compared among treatments, and area under the curve (AUC) for improvement and worsening of effects was determined, enabling ranking of treatments. Further analysis compared pregabalin doses.

Results

Pregabalin without opioids resulted in the highest proportions of patients with ≥ 30% improvement on all pain items and pain interference with “ability to enjoy life,” “activity” “mood,” and “sleep.” For the ≥ 50% threshold, pregabalin alone was highest for all pain interference items and for “average pain” and “worst pain.” Pregabalin was consistently lowest across thresholds for fatigue, but showed better results combined with moderate MED opioids. Pregabalin doses recommended for treatment of FM (151 to 450 mg) generally resulted in the highest proportion of patients achieving thresholds relative to opioids. The AUC results were consistent with thresholds; pregabalin without opioids resulted in the greatest benefits with regard to improvement, with the highest ranking for overall improvement and overall effects.

Conclusion

Pregabalin without opioids provided the most favorable outcomes overall based on ≥ 30% and ≥ 50% improvement thresholds and AUC, with support for moderate MED opioids + pregabalin in patients suffering from fatigue. While most patients took less than recommended pregabalin doses, higher doses may lead to improved outcomes.     

Concerns About Pain and Prescribed Opioids in Taiwanese Oncology Outpatients

Pharmacologic agents are considered to be a cornerstone of cancer pain management. Patients' concerns about use of analgesics are likely to lead to poor pain management. The purpose of this study was to describe participants' responses to their beliefs regarding pain and prescribed opioids. Ninety-two outpatients age ≥18 years who had taken prescribed opioid analgesics for cancer-related pain in two teaching hospitals in the Taipei area completed the Pain Opioid Analgesics Beliefs Scale–Cancer. An important finding of this study is that large numbers of patients had misconceptions about using opioids for pain. Between 33.7% and 68.5% of the patients in this study held negative beliefs about opioids and beliefs about pain. Specifically, 68.5% of the patients agreed that “opioid medication is not good for a person's body.” Many patients (62%) agreed that “the more opioid medicine a patient used, the greater the possibility that he/she might rely on the medicine forever,” and 61.0% agreed that “if a patient starts to use opioid medicine at too early a stage, the medicine will have less of an effect later.” Two-thirds (66.3%) of the sample agreed that adult patients should not use opioid medicine frequently. The findings provide empirical support for the need for better programmatic efforts to improve beliefs of pain and analgesics in Taiwanese oncology outpatients.     

Opioids,Chronic Pain,and Addiction in Primary Care

Research has largely ignored the systematic examination of physicians' attitudes towards providing care for patients with chronic noncancer pain. The objective of this study was to identify barriers and facilitators to opioid treatment of chronic noncancer pain patients by office-based medical providers. We used a qualitative study design using individual and group interviews. Participants were 23 office-based physicians in New England. Interviews were audiotaped, transcribed, and systematically coded by a multidisciplinary team using the constant comparative method. Physician barriers included absence of objective or physiological measures of pain; lack of expertise in the treatment of chronic pain and coexisting disorders, including addiction; lack of interest in pain management; patients' aberrant behaviors; and physicians' attitudes toward prescribing opioid analgesics. Physician facilitators included promoting continuity of patient care and the use of opioid agreements. Physicians' perceptions of patient-related barriers included lack of physician responsiveness to patients' pain reports, negative attitudes toward opioid analgesics, concerns about cost, and patients' low motivation for pain treatment. Perceived logistical barriers included lack of appropriate pain management and addiction referral options, limited information regarding diagnostic workup, limited insurance coverage for pain management services, limited ancillary support for physicians, and insufficient time. Addressing these barriers to pain treatment will be crucial to improving pain management service delivery.