Long-term use of opioids for complex chronic pain

Korff, Michael R. Von

doi:10.1016/j.berh.2013.09.011

Cited by 47 publications

(41 citation statements)

References 87 publications

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“…145 As clinicians' perceptions of the effectiveness and safety of opioids shifted over the past two decades, prescribing increased dramatically. However, the effectiveness of long term opioid therapy for back pain remains unclear, and surveillance data have shown markedly increased rates of opioid overdose and addiction.…”

Section: Resultsmentioning

confidence: 99%

“…After extended release oxycodone was reformulated in 2010, surveillance suggested a reduction in misuse and diversion. 137 138 Practical principles in prescribing opioids for low back pain 145 For all patients with back pain • Emphasize that self care is the foundation of effective back care and that it is usually more important to remain physically active and continue rewarding activities rather than rely on medical prescriptions • An empathetic supportive doctor-patient relationship can encourage effective self care • Rather than monitoring progress by changes in reported pain alone, it may be more effective to guide care towards participation in activities • Differentiate goals of short term pain relief from those of long term effectiveness. For long term use, opioids have unproven benefits and substantial risks…”

Section: Reformulationmentioning

confidence: 99%

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Opioids for low back pain

Deyo

Korff

Duhrkoop³

2015

BMJ

443

329

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Back pain affects most adults, causes disability for some, and is a common reason for seeking healthcare. In the United States, opioid prescription for low back pain has increased, and opioids are now the most commonly prescribed drug class. More than half of regular opioid users report back pain. Rates of opioid prescribing in the US and Canada are two to three times higher than in most European countries. The analgesic efficacy of opioids for acute back pain is inferred from evidence in other acute pain conditions. Opioids do not seem to expedite return to work in injured workers or improve functional outcomes of acute back pain in primary care. For chronic back pain, systematic reviews find scant evidence of efficacy. Randomized controlled trials have high dropout rates, brief duration (four months or less), and highly selected patients. Opioids seem to have short term analgesic efficacy for chronic back pain, but benefits for function are less clear. The magnitude of pain relief across chronic non-cancer pain conditions is about 30%. Given the brevity of randomized controlled trials, the long term effectiveness and safety of opioids are unknown. Loss of long term efficacy could result from drug tolerance and emergence of hyperalgesia. Complications of opioid use include addiction and overdose related mortality, which have risen in parallel with prescription rates. Common short term side effects are constipation, nausea, sedation, and increased risk of falls and fractures. Longer term side effects may include depression and sexual dysfunction. Screening for high risk patients, treatment agreements, and urine testing have not reduced overall rates of opioid prescribing, misuse, or overdose. Newer strategies for reducing risks include more selective prescription of opioids and lower doses; use of prescription monitoring programs; avoidance of co-prescription with sedative hypnotics; and reformulations that make drugs more difficult to snort, smoke, or inject.

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Section: Resultsmentioning

confidence: 99%

Section: Reformulationmentioning

confidence: 99%

Opioids for low back pain

Deyo

Korff

Duhrkoop³

2015

BMJ

443

329

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“…Although opioids are the most commonly used treatments for chronic pain, their use is associated with adverse events, including nausea, constipation, depression, abuse liability and tolerance or loss of efficacy 7, 77 . Thus, exploring alternative analgesic targets is an ongoing goal in pain research.…”

Section: Discussionmentioning

confidence: 99%

Nicotinic modulation of descending pain control circuitry

Umana

Daniele

Miller

et al. 2017

Pain

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Along with the well-known rewarding effects, activation of nicotinic acetylcholine receptors (nAChRs) can also relieve pain, and some nicotinic agonists have analgesic efficacy similar to opioids. A major target of analgesic drugs is the descending pain modulatory pathway, including the ventrolateral periaqueductal gray (vlPAG) and the rostral ventromedial medulla (RVM). Although activating nAChRs within this circuitry can be analgesic, little is known about the subunit composition and cellular effects of these receptors, particularly within the vlPAG. Using electrophysiology in brain slices from adult male rats, we examined nAChR effects on vlPAG neurons that project to the RVM. We found that 63% of PAG-RVM projection neurons expressed functional nAChRs, which were exclusively of the α7-subtype. Interestingly, the neurons that express α7 nAChRs were largely non-overlapping with those expressing µ-opioid receptors (MOR). As nAChRs are excitatory and MORs are inhibitory, these data suggest distinct roles for these neuronal classes in pain modulation. Along with direct excitation, we also found that presynaptic nAChRs enhanced GABAergic release preferentially onto neurons that lacked α7-nAChRs. In addition, presynaptic nAChRs enhanced glutamatergic inputs onto all PAG-RVM projection neuron classes to a similar extent. In behavioral testing, both systemic and intra-vlPAG administration of the α7 nAChR-selective agonist, PHA-543613, was antinociceptive in the formalin assay. Furthermore, intra-vlPAG α7 antagonist pretreatment blocked PHA-543613-induced antinociception via either administration method. Systemic administration of sub-maximal doses of the α7 agonist and morphine produced additive antinociceptive effects. Together, our findings indicate that the vlPAG is a key site of action for α7 nAChR-mediated antinociception.

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“…Accordingly, opioid tolerance and OIH may be improved and exacerbated, respectively, by opioid dose escalation, although the direct clinical impact to OIH has been questioned. 18,23 …”

Section: Opioid Clinical Pharmacologymentioning

confidence: 98%

“…17 Because of these adverse effects, particularly for opioid-naive patients, it is always best to start with a low dose and gradually titrate up. 18 For patients with chronic persistent moderate to severe pain, short-acting opioids can be converted to long-acting opioids in the belief that longacting opioids provide less fluctuation in analgesic blood levels, fewer adverse effects, and require less frequent dosing. However, there are ongoing controversies about the comparable benefits of either opioid dosing formula.…”

Section: Opioid Clinical Pharmacologymentioning

confidence: 99%

Opioid Analgesics

Jamison

Mao

2015

Mayo Clinic Proceedings

109

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Chronic pain is an international health issue of immense importance that is influenced by both physical and psychological factors. Opioids are useful in treating chronic pain but have accompanying complications. It is important for clinicians to understand the basics of opioid pharmacology, the benefits and adverse effects of opioids, and related problematic issues of tolerance, dependence, and opioid-induced hyperalgesia. In this article, the role of psychiatric comorbidity and the use of validated assessment tools to identify individuals who are at the greatest risk for opioid misuse are discussed. Additionally, interventional treatment strategies for patients with chronic pain who are at risk for opioid misuse are presented. Specific behavioral interventions designed to improve adherence with prescription opioids among persons treated for chronic pain, such as frequent monitoring, periodic urine screens, opioid therapy agreements, opioid checklists, and motivational counseling, are also reviewed. Use of state-sponsored prescription drug monitoring programs is also encouraged. Areas requiring additional investigation are identified, and the future role of abuse-deterrent opioids and innovative technology in addressing issues of opioid therapy and pain are presented.

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Long-term use of opioids for complex chronic pain

Cited by 47 publications

References 87 publications

Opioids for low back pain

Opioids for low back pain

Nicotinic modulation of descending pain control circuitry

Opioid Analgesics

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