Opioids in the treatment of non-specific acute and chronic pain
After reading this article, the reader will be familiar with the general classes of opioid agonists and partial agonists, the basics of the pharmacokinetics and pharmacodynamics of opioids, the risks of opioid therapy and the requirements for the safe and effective use of opioids in acute and chronic pain. The use of opioids during surgical procedures or anesthesia is not discussed. Also, there is no discussion about various available opioid antagonists that are used to treat overdose and the various disorders associated with their use (including naloxone and naltrexone). Opioids are available, the most powerful and effective analgesics, and have become acceptable drugs for the treatment of acute and cancerous pain. However, there is concern about their use in case of chronic pain, if there is no cancer, because they are long-range ineffective but best suited for stopping this pain. Opioid prescription must be monitored for better use. Chronic pain creates discomfort for these patients, reducing their productivity and efficiency, which, in turn, can lead to economic problems in the country. The choice of Nalbuphine is due to the following reasons: the opioid, which is comparable to morphine by its analgesic potential, but has a better safety profile for nausea, vomiting and respiratory depression; not subject to strict quantitative accounting (extract on prescription form 1); the choice of opioid analgesics is significantly limited in Ukraine.
GutsteinH, AkilH. Opioid analgesics. In: Hardman JG, Limbird LE, Gilman AG, eds. Goodman & Gilman’s The Pharmacological Basis of Therapeutics. 10th ed. New York: McGrawHill; 2001:569–619.
Yaksh T, Wallace M. Opioids, analgesia and pain management. In: Brunton L, Knollmann B, eds. Goodman and Gilman’s The Pharmacological Basis of Therapeutics. 13th ed. New York: McGraw-Hill; 2017:255–86.
Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recommend Rep. 2016;65(1):1–49.
Errata: Vol. 65, No. 9. MMWR Morbid Mortal Wkly Rep. 2016;65(11):295.
Manchikanti L, Kaye AM, Knezevic NN, et al. Responsible, safe, and effective prescription of opioids for chronic noncancer pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines. Pain Physician. 2017;20(2S): S3–S92.
Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part I – evidence assessment. Pain Physician. 2012;15(3 suppl): S1–S65.
Manchikanti L, Abdi S, Atluri S, et al. American Society of Interventional Pain Physicians (ASIPP) guidelines for responsible opioid prescribing in chronic non-cancer pain: Part 2 – guidance. Pain Physician. 2012;15(3 suppl): S67–S116.
FDA. Draft Revisons to the FDA Education Blueprint for Health Care Providers Involved in the Management or Support of Patients with Pain U.S. Food and Drug Administration. 2017. https://doi. org/10.15585/mmwr.mm655051e1
Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morbid Mortal Wkly Rep. 2016;65(5051):1445–52.
Erratum: Vol. 65, Nos. 50 & 51. MMWR Morbid Mortal Wkly Rep. 2017;66(1):35.
Hermann R, Derendorf H, von Richter O, Rostami-Hodjegan A. Core entrustable professional activities in clinical pharmacology: pearls for clinical practice: drug-drug and food-drug Interactions. J Clin Pharmacol. 2018;58(6):704–16.
Somogyi AA, Barratt DT, Coller JK. Pharmacogenetics of opioids. Clin PharmacolTher. 2007;81(3):429–44.
Sloan PA, Barkin RL. Oxymorphone and oxymorphone extended release: a pharmacotherapeutic review. J Opioid Manage. 2008;4(3):131–44.
Cajanus K, Neuvonen M, Koskela O, et al. Analgesic plasma concentrations of oxycodone after surgery for breast cancerwhich factors matter? Clin PharmacolTher. 2018;103(4):653–62.
Nafziger AN, Bertino JS Jr. Utility and application of urine drug testing in chronic pain management with opioids. Clin J Pain. 2009;25(1):73– 9.
Lam LH, Pirrello RD, Ma JD. A case-based approach to integrating opioid pharmacokinetic and pharmacodynamic concepts in cancer pain management. J Clin Pharmacol. 2016;56(7):785–93.
Herzig SJ, Mosher HJ, Calcaterra SL, Jena AB, Nuckols TK. Improving the safety of opioid use for acute noncancer pain in hospitalized adults: a consensus statement from the Society of Hospital Medicine. J Hosp Med. 2018;13(4):263–71.
Pergolizzi J, Boger RH, Budd K, et al. Opioids and the management of chronic severe pain in the elderly: consensus statement of an International Expert Panel with focus on the six clinically most often used World Health Organization Step III opioids (buprenorphine, fentanyl, hydromorphone, methadone, morphine, oxycodone). Pain Pract. 2008;8(4):287–313.
Wyatt R. Pain and ethnicity. AMA J Ethics. 2013;15(5):449–54. 20. FDA. Extended-Release (ER) and Long-Acting (LA) Opioid Analgesics Risk Evaluation and Mitigation Strategy (REMS). White Oak, MD: US Food and Drug Administration; 2015.
Mayyas F, Fayers P, Kaasa S, Dale O. A systematic review of oxymorphone in the management of chronic pain. J Pain Symptom Manage. 2010;39(2):296–308.
NUCYNTAR (tapentadol) package insert. Canton, MA: Collegium Pharmaceutical, Inc. 2016:1–11.
Pain Treatment with Opioid Medications: Patient Agreement. Sample patient treatment agreement for opioid use. https://www. drugabuse. gov/sites/default/files/files/SamplePatientAgree mentForms.pdf. Accessed April 13, 2018.
Busse JW, Craigie S, Juurlink DN, et al. Guideline for opioid therapy and chronic noncancer pain. Can Med Assoc J. 2017; 189(18): E659–E666.
Volkow ND, McLellan AT. Opioid abuse in chronic pain— misconceptions and mitigation strategies. N Engl J Med. 2016; 374(13):1253–63.
Williams JT, Christie MJ, Manzoni O. Cellular and synaptic adaptations mediating opioid dependence. Physiol Rev. 2001; 81(1):299–343.
Barkin RL, Barkin SJ. Treating postoperative pain in the patient who is in recovery or remission from opioid abuse: focus on tapentadol. J Opioid Manag. 2017;13(3):133–4.
Gammaitoni AR, Fine P, Alvarez N, McPherson ML, Bergmark S. Clinical application of opioid equianalgesic data. Clin J Pain. 2003;19(5):286–97.
Lugo RA, Satterfield KL, Kern SE. Pharmacokinetics of methadone. J Pain Palliat Care Pharmacother. 2005;19(4):13–24.
Fine PG, Portenoy RK, Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation. Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage. 2009;38(3):418–25.
Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113–30.
Gourlay DL, Heit HA. Pain and addiction: managing risk through comprehensive care. J Addict Dis. 2008;27(3):23–30.
Anderson R, Saiers JH, Abram S, Schlicht C. Accuracy in equianalgesic dosing. Conversion dilemmas. J Pain Symptom Manage. 2001;21(5):397–406.
Knotkova H, Fine PG, Portenoy RK. Opioid rotation: the science and the limitations of the equianalgesic dose table. J Pain Symptom Manage. 2009;38(3):426–39.
Shaheen PE, Walsh D, Lasheen W, Davis MP, Lagman RL. Opioid equianalgesic tables: are they all equally dangerous? J Pain Symptom Manage. 2009;38(3):409–17.
Vallejo R, Barkin RL, Wang VC. Pharmacology of opioids in the treatment of chronic pain syndromes. Pain Physician. 2011;14(4):E343– E360.
Levy MH. Pain management in advanced cancer. Semin Oncol. 1985;12(4):394–410.
Duttaroy A, Yoburn BC. The effect of intrinsic efficacy on opioid tolerance. Anesthesiology. 1995;82(5):1226–36.
Smith HS, Peppin JF. Toward a systematic approach to opioid rotation. J Pain Res. 2014; 7: 589–608.
FDA Advisory Committee on the Most Appropriate Dose or Doses of Naloxone to Reverse the Effects of Life-Threatening Opioid Overdose in the Community Settings. Joint Meeting of the Anesthetic and Analgesic Drug Products Advisory Committee and the Drug Safety and Risk Management Advisory Committee on October 5, 2016; Advisory Committee Briefing Materials. https://www.fda.gov/downloads/Advisory Committees/CommitteesMeetingMaterials/Drugs/Anesthetic AndAnalgesicDrugProductsAdvisoryCommittee/UCM522688. pdf. Accessed April 17, 2018.
Jones CM, Einstein EB, Compton WM. Changes in synthetic opioid involvement in drug overdose deaths in the United States, 2010-2016. JAMA. 2018;319(17):1819–21.
Prekupec MP, Mansky PA, Baumann MH. Misuse of novel synthetic opioids: a deadly new trend. J Addict Med. 2017;11(4):256–65.
Schumann H, Erickson T, Thompson TM, Zautcke JL, Denton JS. Fentanyl epidemic in Chicago, Illinois and surrounding Cook County. Clin Toxicol (Phila). 2008;46(6):501–6.
FDA. Disposal of Unused Medicines: What You Should Know. 2018. https://www.fda.gov/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/EnsuringSafeUseofMedicine/SafeDisposalofMedicines/ucm186187.htm Accessed April 14, 2018.
Current Opioid Misuse Measure (COMM)TM. 2008. https://www.opioidprescribing.com/documents/09-comm-inflexxion.pdf. Accessed April 1, 2018.
Pain Assessment and Documentation Tool. 2003. http://www.practiceadvisor.org/docs/default-source/documents/pain_assessment_and_documentation_tool. Accessed April 1, 2018.
Adams LL, Gatchel RJ, Robinson RC, et al. Development of a self -report screening instrument for assessing potential opioid medication misuse in chronic pain patients. J Pain Symptom Manage. 2004;27(5):440–59.
Heit HA, Gourlay DL. Urine drug testing in pain medicine. J Pain Symptom Manage. 2004;27(3):260–7.
Christo PJ, Manchikanti L, Ruan X, et al. Urine drug testing in chronic pain. Pain Physician. 2011;14(2):123–43.
Reisfield GM, Bertholf R, Barkin RL, Webb F, Wilson G. Urine drug test interpretation: what do physicians know? J Opioid Manag. 2007;3(2):80–6.
Argoff CE, Brennan MJ, Camilleri M, et al. Consensus recommendations on initiating prescription therapies for opioidinduced constipation. Pain Med. 2015;16(12):2324–37.
Candy B, Jones L, Goodman ML, Drake R, Tookman A. Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev. 2011(1):CD003448.
Ford AC, Brenner DM, Schoenfeld PS. Efficacy of pharmacological therapies for the treatment of opioid-induced constipation: systematic review and meta-analysis. Am J Gastroenterol. 2013;108(10):1566– 74; quiz 1575.
FDA requires strong warnings for opioid analgesics, prescription opioid cough products, and benzodiazepine labeling related to serious risks and death from combined use [press release]. Silver Spring, MD: US Food and Drug Administration; 2016.
Schuckit MA. Treatment of opioid-use disorders. N Engl J Med. 2016;375(4):357–68.
Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107–12.
Gourlay D, Heit H. Universal precautions: a matter of mutual trust and responsibility. Pain Med. 2006;7(2):210–1; author reply 212.
Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient. Pain Med. 2009;10(suppl 2):S115– S123.
Substance Use Screening & Assessment Instruments Database. 2017. http://lib.adai.washington.edu/instruments/. Accessed April 1, 2018.
American Society of Pain Medicine. Agreement on controlled substances therapy for chronic pain treatment. http://www. painmed.org/ library/clinical-resources/. Accessed April 1, 2018.
SAMHSA. SBIRT: screening, brief intervention, and referral to treatment. https://www.integration.samhsa.gov/clinical-practice/sbirt. Accessed April 1, 2018.
Screening, Brief Intervention and Referral to Treatment (SBIRT) in Behavioral Healthcare. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2011.
Elliot AM, Smith BH. Penny KI, Smith WC, Chambers WA. The epidemiology of chronic pain in the community. Lancet 1999; 354: 1248–52
Crombie IK. Epidemiology of persistent pain. In: Jensen TS, Turner JA, Wiesenfeld-Hallin Z, eds. Proceedings of the 8th World Congress on Pain. Seattle: IASP Press, 1997; 53–61
This work is licensed under a Creative Commons Attribution 4.0 International License