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Treatment Principles for the Use of Opioids in Pain of Nonmalignant Origin

  • Practical Therapeutics
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Summary

Inadequately treated acute and chronic pain remains a major cause of suffering, in spite of enormous advances in pharmacology and technology. Opioids provide a powerful, versatile, widely available means of managing this pain, but their use is too often restrained by ignorance and mistaken fears of addiction.

The management of postoperative pain (perhaps the most common form of acute pain) is traditionally attempted with fixed dosages of analgesics by relatively unpredictable routes (e.g. oral, rectal and intramuscular). Intravenous opioid infusions (an improvement) risk respiratory depression and require close monitoring and titration. Patient-controlled analgesia (PCA), by contrast, permits the most efficacious medication (pure opioid agonist) by the optimal route (intravenous) under direct control of the patient, and provides high levels of satisfaction and safety. Ideally, any opioid use should be integrated with a wide spectrum of other analgesic modalities in an anaesthesiology-based ‘acute pain service’.

The use of opioids for chronic pain of nonmalignant origin remains controversial. There is a perceived conflict between patients’ interests and those of society. However, problems (such as tolerance, physical dependence, addiction and chronic toxicity), anticipated from experience with animal experiments and pain-free abusers, seldom cause difficulties when opioids are used appropriately to treat pain (so-called’ dual pharmacology’).

With sensible guidelines, and in the context of a multidisciplinary pain clinic, opioids may provide the only hope of relief to many sufferers of chronic pain.

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References

  • Ahles TA, Blanchard EB, Ruckdeschel JC. The multidimensional nature of cancer related pain. Pain 17: 277–288, 1983

    Article  PubMed  CAS  Google Scholar 

  • Arner S, Meyerson BA. Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain. Pain 33: 11–23, 1988

    Article  PubMed  CAS  Google Scholar 

  • Bennett RL, Batenhorst RL, Graves D, Foster TS, Baumann T, et al. Morphine titration in postoperative laparotomy patients using patient-controlled analgesia. Current Therapeutic Research 32: 45–52, 1982

    Google Scholar 

  • Bruera E, Macmillan K, Hanson JA, MacDonald RN. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain 39: 13–16, 1989

    Article  PubMed  CAS  Google Scholar 

  • Budd K. Drug management of chronic benign pain. International Disability Studies 9: 30–33, 1987

    Article  PubMed  CAS  Google Scholar 

  • Cartwright PD. Pain control after surgery: a survey of current practice. Annals of the Royal College of Surgeons of England 67: 13–16, 1985

    PubMed  CAS  Google Scholar 

  • Catley DM, Thornton C, Jordan C, Lehane JR, Royston D, et al. Pronounced episodic oxygen desaturation in the postoperative period: its association with ventilatory pattern and analgesic regimen. Anesthesiology 63: 20–28, 1985

    Article  PubMed  CAS  Google Scholar 

  • Chapman CR, Hill HF. Prolonged morphine self-administration and addiction liability. Cancer 63: 1636–1644, 1989

    Article  PubMed  CAS  Google Scholar 

  • Colpaert FC, Niemegeers CJE, Janssen PAJ, Maroli AN. The effects of prior fentanyl administration and of pain on fentanyl analgesia: tolerance to and enhancement of narcotic analgesia. Journal of Pharmacological and Experimental Therapeutics 213: 418–426, 1980

    CAS  Google Scholar 

  • Dahlstrom B, Tamsen A, Paalzow L, Hartvig P. Patient-controlled analgesic therapy. Part IV: pharmacokinetics and analgesic plasma concentrations of morphine. Clinical Pharmacokinetics 7: 266–279, 1982

    Article  PubMed  CAS  Google Scholar 

  • Drew FL, Moriorty RW, Shapiro AP. An approach to the me-surement of the pain and anxiety response of surgical patients. Psychosomatic Medicine 30: 826–836, 1968

    PubMed  CAS  Google Scholar 

  • Duthie DJR, Nimmo WS. Adverse effects of opioid analgesic drugs. British Journal of Anaesthesia 59: 61–77, 1987

    Article  PubMed  CAS  Google Scholar 

  • Etches RC, Sandler AN, Daley MD. Respiratory depression and spinal opioids. Canadian Journal of Anaesthesia 36: 165–185, 1989

    Article  PubMed  CAS  Google Scholar 

  • Evans PJD. Narcotic addiction in patients with chronic pain. Anaesthesia 36: 597–602, 1981

    Article  PubMed  CAS  Google Scholar 

  • Friedman OP. Perspectives on the medical use of drugs of abuse. Journal of Pain and Symptom Management 5: S2–5, 1990

    PubMed  CAS  Google Scholar 

  • Fry ENS. Postoperative analgesia: a technique using continuous infusion of buprenorphine. Anaesthesia 39: 1134–1135, 1984

    Article  PubMed  CAS  Google Scholar 

  • Gallagher RM, Stewart FI, Weissbein T, Weissbein A. Nonnarcotic analgesic abuse. A common biopsychosocial problem. General and Hospital Psychiatry 10: 102–107, 1988

    Article  Google Scholar 

  • Gaukroger PB. Paediatric analgesia. Which drug? Which dose? Drugs 41: 52–59, 1991

    Article  PubMed  CAS  Google Scholar 

  • Glynn CJ, Mather LE. Clinical pharmacokinetics applied to patients with intractable pain: studies with pethidine. Pain 13: 237–246, 1982

    Article  PubMed  CAS  Google Scholar 

  • Gold MS, Pottash AC, Sweeney DR, Kleber HD. Opiate withdrawal using clonidine. A safe effective and rapid non-opiate treatment. Journal of the American Medical Association 243: 343–346, 1980

    Article  PubMed  CAS  Google Scholar 

  • Gourlay GK, Cousins MJ. Strong analgesics in severe pain. Drugs 28: 79–91, 1984

    Article  PubMed  CAS  Google Scholar 

  • Grabinski PY, Kaiko RF, Rogers AG, Houde RW. Plasma levels and analgesia following deltoid and gluteal injections of methadone and morphine. Journal of Clinical Pharmacology 23: 48–55, 1983

    PubMed  CAS  Google Scholar 

  • Gritz ER, Shiffman SM, Jarvik ME. Physiological and psychological effects of methadone in man. Archives of General Psychiatry 32: 237–242, 1975

    Article  PubMed  CAS  Google Scholar 

  • Gustafsson LL, Wiesenfeld-Hallin Z. Spinal opioid analgesia: a critical update. Drugs 35: 597–603, 1988

    Article  PubMed  CAS  Google Scholar 

  • Hampton JR. Management of the pain of myocardial infarction. In Harcus AW et al. (Eds) Pain — new perspectives in measurement and management, pp. 97–102, Churchill Livingstone, Edinburgh, 1977

    Google Scholar 

  • Hayes MJ, Fraser AR, Hampton JR. Randomized trial comparing buprenorphine and diamorphine for chest pain in suspected myocardial infarction. British Medical Journal 2: 300–302, 1979

    Article  PubMed  CAS  Google Scholar 

  • Henn C, Lehmann KA. Praediktoren des postoperativen Schmerzes. In Lehmann KA (Ed.) Der postoperative Schmerz, pp. 55–85, Springer Verlag, Berlin, 1990

    Google Scholar 

  • Holley FD, van Stennis RN. Transdermal application of fentanyl for postoperative analgesia. Anesthesiology 65 (Suppl.): A548 1986

    Article  Google Scholar 

  • Hoskin PJ, Hanks GW. Opioid agonist-antagonist drugs in acute and chronic pain states. Drugs 41: 326–344, 1991

    Article  PubMed  CAS  Google Scholar 

  • Hug CC. Pharmacokinetics and dynamics of narcotic analgesics. In Prys-Roberts C & Hug CC (Eds) Pharmacokinetics of anaesthesia, pp. 187–234, Blackwell Scientific Publications, Oxford, 1984

    Google Scholar 

  • Hunt CO, Nauity JS, Bader AM, Hauch MA, Vartikar JV, et al. Perioperative analgesia with subarachnoid fentanyl-bupivacaine for caesarean delivery. Anaesthesiology 71: 535–540, 1989

    Article  CAS  Google Scholar 

  • Jackson D. Cost efficiency of PCA. Journal of Intravenous Nursing 12: 4, 1989

    Google Scholar 

  • Jewitt DE, Maurer BJ, Hubner PJB. Increased pulmonary artery pressure after pentazocine in myocardial infarction. British Medical Journal 1: 795–798, 1970

    Article  PubMed  CAS  Google Scholar 

  • Jones L, Neiswender JA, Perkins M. PCA: Patient satisfaction, nursing satisfaction and cost effectiveness. Nursing Management 20: 16–17, 1989

    PubMed  CAS  Google Scholar 

  • Kaiko RF, Wallenstein SZ, Rogers AG, Grabinski PY, Houde RW. Narcotics in the elderly. Medical Clinics of North America 66: 1079–1089, 1982

    PubMed  CAS  Google Scholar 

  • Keeri-Szanto M. Drugs or drums: what relieves postoperative pain? Pain 6: 217–230, 1979

    Article  PubMed  CAS  Google Scholar 

  • Kreek MJ. Medical safety and side effects of methadone in tolerant individuals. Journal of the American Medical Association 223: 665–668, 1973

    Article  PubMed  CAS  Google Scholar 

  • Kreek MJ, Dodes S. Long-term methadone maintenance therapy: effects on liver function. Annals of Internal Medicine 77: 598–602, 1972

    PubMed  CAS  Google Scholar 

  • Lee G, DeMaria AN, Amsterdam EA, Realyvasquez P, Angel J, et al. Comparative effects of morphine, meperidine and pentzocine on cardio-circulatory dynamics in patients with acute myocardial infarction. American Journal of Medicine 60: 949–952, 1976

    Article  PubMed  CAS  Google Scholar 

  • Lehmann KA. Practical experience with demand analgesia for postoperative pain. In Harmer M, et al. (Eds) Patient-controlled analgesia, pp. 134–139, Blackwell Scientific Publications, Oxford 1985

    Google Scholar 

  • Lehmann K. On-demand Analgesie. In Lehmann KA (Ed.) Der postoperative Schmerz, pp. 237–265, Springer Verlag, Berlin, 1990

    Google Scholar 

  • Lehmann KA, Henn C. Zur Lage de postoperativen Schmerztherapie in der Bundesrepublik Deutschland: Ergebnisse einer Repraesentativumfrage. Anaesthesist 36: 400–406, 1987

    PubMed  CAS  Google Scholar 

  • Lehmann KA, Reichling U, Wirtz R. Influence of naloxone on the postoperative analgesic and respiratory effects of buprenorphine. European Journal of Clinical Pharmacology 34: 343–352, 1988

    Article  PubMed  CAS  Google Scholar 

  • Loan WB, Morrison JD. The incidence and severity of postoperative pain. British Journal of Anaesthesia 39: 695–698, 1967

    Article  PubMed  CAS  Google Scholar 

  • Lombardo WK, Lombardo B, Goldstein A. Cognitive functioning under moderate and low dose methadone maintenance. Journal of Nervous and Mental Disability 148: 606–614, 1969

    Article  Google Scholar 

  • Maruta T, Swanson DW. Problems with the use of oxycodone compounds in patients with chronic pain. Pain 11: 389–396, 1981

    Article  PubMed  CAS  Google Scholar 

  • Maruta T, Swanson DW, Finlayson RE. Drug abuse and dependency in patients with chronic pain. Mayo Clinic Proceedings 54: 241–244, 1979

    PubMed  CAS  Google Scholar 

  • Mather LE, Mackie J. The incidence of postoperative pain in children. Pain 15: 271–282, 1983

    Article  PubMed  CAS  Google Scholar 

  • Mather LE, Owen H. The scientific basis of patient-controlled analgesia. Anaesthesia and Intensive Care 16: 427–447, 1988

    PubMed  CAS  Google Scholar 

  • McKenzie R. Patient-controlled analgesia (PCA). Anesthesiology 69: 1027, 1988

    Article  PubMed  CAS  Google Scholar 

  • McQuay HJ. Opioids in chronic pain. British Journal of Anaesthesia 63: 213–216, 1989

    Article  PubMed  CAS  Google Scholar 

  • Melzack R. The tragedy of needless pain. Scientific American 162: 19–25, 1990

    Google Scholar 

  • Merry AF, Schug SA, Richards EGR, Large RG. Opioids in the treatment of chronic pain of non malignant origin in New Zealand. New Zealand Medical Journal submitted for publication, 1991

    Google Scholar 

  • Merskey H. Classification of chronic pain. Pain (Suppl. 3): 1, 1986

    Google Scholar 

  • Miser AW, Narang PK, Dothage JA, Young RC, Sindelar W, et al. Transdermal fentanyl for pain control in patients with cancer. Pain 37: 15–21, 1989

    Article  PubMed  CAS  Google Scholar 

  • Morgan JP. American opiophobia: customary underutilization of opioid analgesics. Advances in Alcohol and Substance Abuse 5: 163–173, 1985

    Article  PubMed  CAS  Google Scholar 

  • Morgan M. The rational use of intrathecal and extradural opioids. British Journal of Anaesthesia 63: 165–188, 1989

    Article  PubMed  CAS  Google Scholar 

  • Owen H, Plummer JL, Armstrong I, Mather LE, Cuosins MJ. Variables of patient-controlled analgesia 1. bolus size. Anaesthesia 44: 7–10, 1989a

    Article  PubMed  CAS  Google Scholar 

  • Owen H, Szekely SM, Plummer L, Cushnie JM, Mather LE. Variables of patient-controlled analgesia. 2. Concurrent infusion. Anaesthesia 44: 11–13, 1989b

    Article  PubMed  CAS  Google Scholar 

  • Portenoy RK. Chronic opioid therapy in nonmalignant pain. Journal of Pain and Symptom Management 5: S46–62, 1990

    Article  PubMed  CAS  Google Scholar 

  • Portenoy RK, Foley KM. Chronic use of opioid analgesic in nonmalignant pain: report of 38 cases. Pain 25: 171–186, 1986

    Article  PubMed  CAS  Google Scholar 

  • Portenoy RK, Foley KM, Inturrisi CE. The nature of opioid responsiveness and its implications for neuropathic pain: new hypothesis derived from studies of opioid infusions. Pain 43: 273–286, 1990

    Article  PubMed  CAS  Google Scholar 

  • Radnay PA, Brodman E, Mankikar D, Duncalf D. The effect of equi-analgesic doses of fentanyl, morphine, meperidine, and pentazocine on common bile duct pressure. Anaesthetist 29: 26–29, 1980

    CAS  Google Scholar 

  • Ready LB. Patient-controlled analgesia: does it provide more than comfort. Canadian Journal of Anaesthesia 37: 719–721, 1990

    Article  PubMed  CAS  Google Scholar 

  • Ready LB, Oden R, Chadwick HS, Benedetti C, Rooke GA, et al. Development of an anaesthesiology-based postoperative pain management service. Anesthesiology 68: 100–106, 1988

    Article  PubMed  CAS  Google Scholar 

  • Ready LB, Sarkis E, Turner JA. Self-reported vs. actual use of medications in chronic pain patients. Pain 12: 285–294, 1982

    Article  PubMed  CAS  Google Scholar 

  • Robins LN, Davis DH, Nurco DN. How permanent was Vietnam drug addiction. American Journal of Public Health 64: 38–43, 1974

    Article  PubMed  Google Scholar 

  • Ross EL, Perumbetti P. PCA: Is it cost effective when used for postoperative pain management? Anesthesiology 69: A710, 1988

    Article  Google Scholar 

  • Runciman WB, Mather LE, Owen H. Opiatagonisten: Anwendung und Dosierung. In Lehmann KA (Ed.) Der postoperative Schmerz, pp. 174–189, Springer Verlag, Berlin, 1990

    Google Scholar 

  • Schug S, Zech D, Doerr U. The use of morphine in cancer pain: a German problem? Journal of Pain and Symptom Management 3: S26, 1988

    Article  Google Scholar 

  • Schug S, Zech D, Doerr U. Cancer pain management according to WHO guidelines. Journal of Pain and Symptom Management 5: 27–32, 1990a

    Article  PubMed  CAS  Google Scholar 

  • Schug S, Zech D, Grond S. Morphine doses in the management of cancer pain. Pain (Suppl. 5): S365, 1990b

    Google Scholar 

  • Sechzer PH. Studies in pain with analgesic-demand systems. Anesthesia and Analgesia 50: 1–10, 1971

    Article  PubMed  CAS  Google Scholar 

  • Stapleton JV, Austin KL, Mather LE. A pharmacokinetic approach to postoperative pain: continuous infusion of pethidine. Anaesthesia and Intensive Care 7: 25–32, 1979

    PubMed  CAS  Google Scholar 

  • Swerdlow M, Murray A, Daw RH. A study of postoperative pain. Acta Anaesthesiologica Scandinavica 7: 1–19, 1963

    Article  PubMed  CAS  Google Scholar 

  • Taub A. Opioid analgesics in the treatment of chronic intractable pain of non-neoplastic origin. In Kitahata LM & Collins JG (Eds) Narcotic analgesics in anaesthesiology, pp. 199–208, Williams & Wilkins, Baltimore, 1982

    Google Scholar 

  • Tennant FS, Uelman GF. Narcotic maintenance for chronic pain. Postgraduate Medicine 73: 81–94, 1983

    Google Scholar 

  • Turner JA, Calsyn DA, Fordyce WE, Ready LB. Drug utilization patterns in chronic pain patients. Pain 12: 357–363, 1982

    Article  PubMed  CAS  Google Scholar 

  • Urban BJ, France RD, Steinberger ΕΚ, Scott DL, Maltbie AA. Long-term use of narcotic/antidepressant medication in the management of phantom limb pain. Pain 24: 191–196, 1986

    Article  PubMed  CAS  Google Scholar 

  • Wall PD. Neuropathic pain. Editorial. Pain 43: 267–268, 1990

    Article  PubMed  CAS  Google Scholar 

  • Wasylak TJ, Abbott FV, English MJM, Jeans ME. Reduction of postoperative morbidity following patient-controlled morphine. Canadian Journal of Anaesthesia 37: 726–731, 1990

    Article  PubMed  CAS  Google Scholar 

  • Way WL. Basic mechanism in narcotic tolerance and physical dependence. Annals of the New York Academy of Sciences 311: 61–68, 1978

    Article  PubMed  CAS  Google Scholar 

  • Weis OF, Sriwatanakul K, Alloza JL, Weintraub M, Lasagna L. Attitudes of patients, housestaff and nurses toward postoperative analgesic care. Anesthesia and Analgesia 62: 70–74, 1983

    PubMed  CAS  Google Scholar 

  • Weissman DE, Haddox JD. Opioid pseudoaddiction: an iatrogenic syndrome. Pain 36: 363–364, 1989

    Article  PubMed  CAS  Google Scholar 

  • White PF. Mishaps with patient-controlled analgesia. Anesthesiology 66: 81–83, 1987

    Article  PubMed  CAS  Google Scholar 

  • Woods JH, Winger G. Opioids, receptors and abuse liability. In Meitzer HY (Ed.) Neural blockade in clinical anaesthesia and management of pain, 2nd ed., pp. 885–898, Lippincott, Philadelphia, 1988

    Google Scholar 

  • World Health Organization. Cancer pain relief, WHO, Geneva, 1986

    Google Scholar 

  • Ziesat HA. Drug use and misuse in operant pain patients. Addictive Behaviours 4: 263–266, 1979

    Article  CAS  Google Scholar 

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  1. Pain Clinic, Auckland Hospital, Park Road, Auckland 1, New Zealand

    S. A. Schug, A. F. Merry & R. H. Acland

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Schug, S.A., Merry, A.F. & Acland, R.H. Treatment Principles for the Use of Opioids in Pain of Nonmalignant Origin. Drugs 42, 228–239 (1991). https://doi.org/10.2165/00003495-199142020-00005

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