Time-scheduled vs. pain-contingent opioid dosing in chronic opioid therapy

Abstract

Some expert guidelines recommend time-scheduled opioid dosing over pain-contingent dosing for patients receiving chronic opioid therapy (COT). The premise is that time-scheduled dosing results in more stable opioid blood levels and better pain relief, fewer side effects, less reinforcement of pain behaviors, and lower addiction risk. We report results of a survey of 1781 patients receiving COT for chronic non-cancer pain, in which 967 reported time-scheduled opioid dosing only and 325 reported pain-contingent opioid dosing only. Opioid-related problems and concerns were assessed with the Prescribed Opioids Difficulties Scale. We hypothesized that respondents using time-scheduled opioid dosing would report significantly fewer problems and concerns than those using pain-contingent dosing. Patients receiving time-scheduled dosing received substantially higher average daily opioid doses than those using pain-contingent dosing (97.2 vs. 37.2 milligrams average daily dose morphine equivalents, p<.0001). Contrary to expectation, timescheduled opioid dosing was associated with higher levels of patient opioid control concerns than pain-contingent dosing (6.2 vs. 4.8, p=.008), after adjusting for patient and drug regimen differences. Opioid-related psychosocial problems were somewhat greater among patients using time-scheduled dosing, but this difference was non-significant after controlling for patient and drug regimen differences (5.9 versus 5.0, p=.14). Time-scheduled dosing typically involved higher dosage levels and was associated with higher levels of patient concerns about opioid use. Controlled comparative effectiveness research is needed to assess benefits and risks of timescheduled opioid dosing relative to pain-contingent opioid dosing among COT patients in ambulatory care.Address correspondence to Dr. Michael Von Korff: 206-287-2874 (Phone) 206-287-2871 Vonkorff.m@ghc.org. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. Empirical research on time-scheduled opioid dosing has largely concerned postoperative pain management. A structured review on time-scheduled opioid dosing for post-operative pain management [12] concluded that there is "sparse empirical work warranting endorsement of this dosing regimen." Subsequently, several trials of time-scheduled opioid dosing reported benefits relative to pain-contingent dosing in postoperative pain management [6,7,11,19]. Whether findings for time-scheduled opioid dosing in postoperative pain management translate to COT in ambulatory care settings has not been examined.Lack of evidence regarding the effectiveness of time...

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