Opioids in the Treatment of Chronic Pain: Legal Framework and Therapeutic Indications and Limitations

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Federal regulation

Medical school curriculum rarely includes instruction about governmental regulation of medical practice. The government authorizes medical use of medications such as opioids through two distinct categories of laws: (1) controlled substance acts (CSAs) that regulate physiologically active chemicals, and (2) health care practice acts (HPAs) that set standards of medical practice [1]. Hierarchically, federal law takes precedence over state law, which can be more restrictive than federal

State regulations

The legislation of the state where a physician is licensed and practices may be more restrictive than federal law. The University of Wisconsin Medical School's Pain Policy website, www.medsch.wisc.edu/painpolicy, has compiled each state's legislation or medical board guidelines regarding chronic pain treatment or opioid prescription [12]. Policies regarding pain treatment (pt) or the use of controlled substances (cs) are as follows:

  • Medical Board Policy Statement (MBPS): CT (cs for pt); NY (cs

Resources and tools

Various professional and patient organizations provide information and practice tools. The International Association for the Study of Pain (www.iasp-pain.org), its American chapter, the American Pain Society (www.ampainsoc.org), and its patient resource organization, the National Pain Foundation (www.painfoundation.org), provide links to pertinent sites and resources. The American Academy of Pain Medicine (www.painmed.org) provides links to an English language consent form for long-term opioids

Peer and patient attitudes

Although the World Health Organization has indicated that morphine and other opioids are “essential” drugs that should be available in all countries for medical treatment [18], even experts do not agree that opioids are appropriate treatment for persons with intractable pain [1]. Nonspecialists, patients, and regulators are uncertain about opioids' role. Turk and coworkers [23] surveyed clinicians nationwide and found that, although opioids were prescribed in all regions of the country by

Historical perspective

The soporific and medicinal use of opioids spans millennia. American suspicion regarding opioids spans more than a century. Arab traders propagated opium's medicinal use to Europe in the fifteenth century [28]. The bitter chemical could be smoked or ingested as a pill or an alcohol-opium mixture, laudanum [28]. Sertürner isolated morphine, the most active alkaloid in opium, in 1805 [29]. Historical uses of opiates included “intermittent fever” (malaria), wounds and fractures, burns, dysentery,

Considerations before and during opioid treatment: urine drug screens

Owing to federal regulation, physicians provide the only legal access to opioids in this country [34]. Because opioids not only treat pain, a medical prerogative, but also subserve addictive illness and black market commerce, physicians have become reluctant travelers on a convoluted course. Angarola and Joranson [18] argue that, “People suffering from pain…did not choose the disease that afflicts them. They should not have to suffer because a controlled substance is the appropriate treatment

Opioid efficacy for intractable pain

One review article and two systematic reviews comment on the practice of prescribing opioids for the relief of chronic pain and summarize the available randomized controlled trials of the practice. Surveys and uncontrolled case series out to 6 years suggest that patients with chronic pain can achieve satisfactory analgesia on stable doses of narcotics with a minimal risk of addiction [34]. Except in the several days after opioid dose increases, psychomotor abilities such as driving are

Pharmacology of opioids

Acting on mu (μ) receptors in the periaqueductal gray, morphine and other opioids effect analgesia by inhibiting ascending pathway information about nociception. The affect of opioids could simplistically be said to be a function of the “descending pathways” that modulate the experience of pain. Morphine does not affect other sensory integration and, generally, more effectively decreases sharp intermittent pain than dull aching pain [29]. The analgesic and various other effects of opioids are

Opioid rotation to treat tolerance

One strategy for restoring opioid efficacy when tolerance develops is opioid rotation [51], [52]. Opioid rotation has also been employed to relieve opioid toxicity [53]. In the palliative care setting, subjects were rotated off one narcotic to another for signs of toxicity (cognitive failure, hallucinations, myoclonus, nausea and vomiting, local toxicity) or persistent pain [53]. Symptoms improved in a significant (73%) percentage of patients; also significant were a decrease in narcotic

Neuropathic pain and opioids

The occurrence and perpetuation of inflammatory pain, ischemic pain, and neuropathic pain involve the N-methyl-D-aspartate receptor, which is activated by glutamate and associated with a reduction in sensitivity to opioids [52]. In 1988, Arner and Meyerson [54] ignited a controversy regarding the efficacy of opioids for pain relief in neuropathic pain states. In a randomized, placebo-controlled trial of intravenous morphine, nociceptive pain was significantly relieved but neuropathic and

Case 1

A 19-year-old man presents with motorcycle crash and traumatic brain injury and probably centrally mediated neuropathic pain. Tricylic antidepressants will probably compound compromised cognitive function. Opioids have not been shown to decrease central pain meaningfully, and, given their other liability, I would probably direct pain relief efforts at treatment of the spasticity.

Case 2

A 70-year-old woman presents with 10 years of diabetes mellitus, neuropathic type foot pain, and poor sleep. If the

Summary

The most important message that physicians must communicate to persons with chronic pain is that, currently, no medication exists that will take away more than 30% of the pain they experience. Chronic pain is a chronic disease and, like diabetes or hypertension, requires chronic concessions and lifestyle modifications. In controlled trials of short duration and small sample size with highly selected patients, patients sustaining moderate-to-severe pain still experience moderate pain even on

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