Opioid tolerance: the clinical perspective

Abstract

Uncertainty about the clinical significance of tolerance to opioid analgesia has important and diverse implications. Although understanding of the characteristics and mechanisms of experimental tolerance has grown, the clinical correlates and ramifications of these findings remain ambiguous to practitioners prescribing long-term opioid therapy to patients for the treatment of malignant and non-malignant pain. In this review I shall discuss clinical aspects of tolerance and the associated phenomena of dependence, withdrawal and addiction to opioids as they apply to the practice of clinicians who manage patients with chronic malignant and non-malignant pain.

Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients

“…For example, among an array of demographic variables, only the variables of martial status and disability payment status showed significant differences in distributions between High and Low PMQ scoring groups. The higher prevalence in the H-PMQ group of patients collecting disability is consistent with earlier proposals that people with higher levels of disability might be at greater risk for opioid misuse [1,42]. Results from the analysis of martial status relative to PMQ score appear more complex.…”

Opioids in chronic noncancer pain

“…By contrast, physical dependence is the development of an altered physiological state that is revealed by an opioid withdrawal syndrome involving autonomic and somatic hyperactivity. Two types of tolerance have been described, including innate tolerance, which is genetically determined and would be present from the initial dose of the opioid, and acquired tolerance, which is based on pharmacokinetic, pharmacodynamic and learned activity [78]. Pharmacokinetic tolerance results from changes in the metabolism of a drug after repeated administration, such as the induction of an enzyme by the administration of the drug itself, whereas pharmacodynamic tolerance is represented by the drug itself.…”

Risk Factors in Opioid Treatment of Chronic Non-Cancer Pain: A Multidisciplinary Assessment

“…Physicians may not prescribe opioids at adequate doses because they do not know how to use them effectively, because they do not assess the pain or effects of treatment systematically, because of fear of sanctions by medical commissions. But some data lead one to believe that the overestimation of the risk of addiction is a significant problem (Dews & Mekhail, 2004); in this respect, the term opiophobia has been coined, to refer to the practice of under-prescription of opioid medication due to the fear of inducing addiction in patients (Collett, 1998). By interviewing over 248 US physicians, Bhamb et al (2006) recently reported that just over half of those interviewed (55.9%), had specific clinical protocols for the prolonged use of opioids in patients with chronic non-cancer pain.…”