Objective. This article reviews the potential physical and psychological consequences of chronic pain and the importance of implementing effective therapeutic strategies to mitigate the harms ...associated with inadequate treatment.
Results. A review of recent literature examining the neurobiology and pathophysiology of chronic pain reveals that this highly prevalent condition negatively impacts multiple aspects of patient health, including sleep, cognitive processes and brain function, mood/mental health, cardiovascular health, sexual function, and overall quality of life. Furthermore, chronic pain has the capacity to become increasingly complex in its pathophysiology, and thus potentially more difficult to treat over time. The various health complications related to chronic pain can also incur significant economic consequences for patients.
Conclusions. Like other chronic conditions, it is important that chronic pain is managed with the objective of minimizing or avoiding its associated long‐term sequelae. In line with this approach, early and effective multimodal treatment strategies, including analgesic therapy that controls pain intensity, are essential to improving outcomes and returning patients to normal levels of function.
After three and a half decades of experience with the Medicare hospice benefit in the U.S., despite excellent quality outcomes in symptom management, patient and family satisfaction, and reduction in ...health care costs, only 12%–15% of beneficiaries' days during the last year of life are spent being cared for within the highly cost-effective interdisciplinary coordinated advanced illness care model known as hospice. Although there are many reasons for this, including difficulties in acknowledging mortality among patients, their families, and physicians, a significant cause of low overall hospice utilization and intractably low median lengths of stay, reflective of late admissions, can be attributed to increasingly difficult and highly variable prognostic determinations for most of the leading causes of death among Medicare beneficiaries.
Medicare is the payer for most hospice care in the U.S. and requires certification of a prognosis of six months or less for a beneficiary to access hospice support. At the time of admission to hospice, two physicians must predict that a patient is more likely to die in the next six months than survive, based on clinical status. In addition to prognostic uncertainty constituting a barrier to timely hospice referral, the Centers for Medicare and Medicaid Services and its payer contractors have developed a robust and expensive retrospective review process that penalizes hospices when patients outlive their expected prognosis. The administratively burdensome and financially punitive review practices further delay or limit access to care for eligible patients as certifying physicians and agencies, fearful of the financial and legal repercussions of reviews and audits, are hesitant to take patients under care unless they are clearly in the dying process. This article will review pertinent history and address the core problem of access to a health care benefit built on a policy that requires far greater prognostic certainty than any clinician can reasonably ascertain and fails to take into consideration the favorable impact hospice care has on terminally ill patients in improving prognosis. This clinical conundrum that limits access of seriously ill people to high-value quality care is of profound importance to the U.S. Medicare population and also one with potential relevance to all complex and regulated health systems and to other models of care whose eligibility criteria are based on prognostication.
Abstract Opioid rotation refers to a switch from one opioid to another in an effort to improve the response to analgesic therapy or reduce adverse effects. It is a common method to address the ...problem of poor opioid responsiveness despite optimal dose titration. Guidelines for opioid rotation are empirical and begin with the selection of a safe and reasonably effective starting dose for the new opioid, followed by dose adjustment to optimize the balance between analgesia and side effects. The selection of a starting dose must be based on an estimate of the relative potency between the existing opioid and the new one. Potency, which is defined as the dose required to produce a given effect, differs widely among opioids, and among individuals under varying conditions. To effectively rotate from one opioid to another, the new opioid must be started at a dose that will cause neither toxicity nor abstinence, and will be sufficiently efficacious in that pain is no worse than before the change. The estimate of relative potency used in calculating this starting dose has been codified on “equianalgesic dose tables,” which historically have been based on the best science available and have been used with little modification for more than 40 years. These tables, and the clinical protocols used to apply them to opioid rotation, may need revision, however, as the science underlying relative potency evolves. Review of these issues informs the use of opioid rotation in the clinical setting and defines key areas for future research.
Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the ...evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.
Safe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
Background. Chronic or persistent pain is a common problem in older adults and is often associated with significant physical disability and psychosocial problems. The potential benefits, risks, and ...costs of pharmacotherapy as a mainstay in the treatment of moderate to severe pain in this population must be well‐understood and weighed accordingly. Recent treatment guidelines have been introduced that can guide decision making to optimize pain‐related treatment outcomes in older individuals
Objectives and Results. This review article describes and summarizes key evidence‐based recommendations that were derived by a committee convened by the American Geriatrics Society in order to provide guidance to optimize pharmacotherapy in the management of persistent pain in older individuals.
Conclusions. It is postulated that ongoing education of clinicians who treat older patients with persistent moderate to severe pain will lead to improved outcomes in this vulnerable population.
Optimal methods to predict risk of aberrant drug-related behaviors before initiation of opioids for chronic noncancer pain and to identify aberrant behaviors after therapy is initiated are uncertain. ...We systematically reviewed published literature identified through searches of Ovid MEDLINE and the Cochrane databases through July 2008. Diagnostic test characteristics and accompanying confidence intervals were calculated with data extracted from the studies. Four prospective studies evaluated diagnostic accuracy of risk prediction instruments. Two higher-quality derivation studies found that high scores on the Screener and Opioid Assessment for Patients with Pain (SOAPP) Version 1 and the Revised SOAPP (SOAPP-R) instruments weakly increased the likelihood for future aberrant drug-related behaviors (positive likelihood ratios PLR, 2.90 95% CI, 1.91 to 4.39 and 2.50 95% CI, 1.93 to 3.24, respectively). Low scores on the SOAPP Version 1 moderately decreased the likelihood for aberrant drug-related behaviors (negative likelihood ratio NLR, 0.13 95% CI, 0.05 to 0.34) and low scores on the SOAPP-R weakly decreased the likelihood (NLR, 0.29 95% CI, 0.18 to 0.46), but estimates are too imprecise to determine if there is a difference between these instruments. One lower-quality study found that categorization as high risk using the Opioid Risk Tool strongly increased the likelihood for future aberrant drug-related behaviors (PLR, 14.3 95% CI, 5.35 to 38.4) and classification as low risk strongly decreased the likelihood (PLR, 0.08 95% CI, 0.01 to 0.62). Nine studies evaluated monitoring instruments for identification of aberrant drug-related behaviors in patients on opioid therapy. One higher-quality derivation study found higher scores on the Current Opioid Misuse Measure (COMM) weakly increased the likelihood of current aberrant drug-related behaviors (PLR, 2.77 95% CI, 2.06 to 3.72) and lower scores weakly decreased the likelihood (NLR, 0.35 95% CI, 0.24 to 0.52). In 8 studies of other monitoring instruments, diagnostic accuracy was poor, results were difficult to interpret due to methodological shortcomings, or standard diagnostic test characteristics were not reported. Definitions for aberrant drug-related behaviors were not standardized across studies and did not account for seriousness of identified behaviors. No reliable evidence exists on accuracy of urine drug screening, pill counts, or prescription drug monitoring programs; or clinical outcomes associated with different assessment or monitoring strategies.
Evidence on prediction and identification of aberrant drug-related behaviors is limited. Although several screening instruments may be useful, evidence is sparse and primarily based on derivation studies, and methodological shortcomings exist in all studies. Research that performs external validation, uses standardized definitions for clinically relevant aberrant drug-related behaviors, and evaluates clinical outcomes associated with different assessment and monitoring strategies is needed.
Abstract Opioid rotation is a strategy applied during opioid therapy for pain that refers to a switch from one opioid to another in an effort to improve clinical outcomes (benefits or harms). It ...begins with the selection of a new drug at a starting dose that minimizes potential risks while ideally maintaining analgesic efficacy. The selection of a starting dose must be informed by an estimate of the relative potency between the existing opioid and the new one. Clinically relevant estimates of relative analgesic potency have been codified in the “equianalgesic dose table,” which has been used with little modification for more than 40 years. New information about relative potency and the growing implementation of long-term opioid therapy for chronic pain provided a strong rationale for the convening of an expert panel to discuss the scientific foundation to opioid rotation and the elements that now should inform a clinical guideline for this practice. The panel affirmed both the value and the limitations of the current equianalgesic dose table and proposed a guideline intended to promote safety during opioid rotation.
Fibromyalgia syndrome (FMS) is a prevalent and disabling chronic pain disorder. Past research suggests that obesity is a common comorbidity and may be related to the severity of FMS. The main ...objective of the present study was to evaluate the relationships between FMS and obesity in the multiple FMS-related domains: hyperalgesia, symptoms, physical abilities, and sleep. A total of 215 FMS patients completed a set of self-report inventories to assess FMS-related symptoms and underwent the tender point (TP) examination, physical performance testing, and 7-day home sleep assessment. Forty-seven percent of our sample was obese and an additional 30% was overweight. Obesity was related significantly to greater pain sensitivity to TP palpation particularly in the lower body areas, reduced physical strength and lower-body flexibility, shorter sleep duration, and greater restlessness during sleep. The results confirmed that obesity is a prevalent comorbidity of FMS that may contribute to the severity of the problem. Potential mechanisms underlying the relationship are discussed.
This report presents how obesity may be interrelated to fibromyalgia pain, disability, and sleep. We found that obesity is common in FMS. Approximately half of our patients were obese and an additional 30% were overweight. We also found that obesity in FMS was associated with greater pain sensitivity, poorer sleep quality, and reduced physical strength and flexibility. The results suggest that obesity may aggregate FMS and weight management may need to be incorporated into treatments.
The endocannabinoid system is involved in a host of homeostatic and physiologic functions, including modulation of pain and inflammation. The specific roles of currently identified endocannabinoids ...that act as ligands at endogenous cannabinoid receptors within the central nervous system (primarily but not exclusively CB 1 receptors) and in the periphery (primarily but not exclusively CB 2 receptors) are only partially elucidated, but they do exert an influence on nociception. Exogenous plant-based cannabinoids (phytocannabinoids) and chemically related compounds, like the terpenes, commonly found in many foods, have been found to exert significant analgesic effects in various chronic pain conditions. Currently, the use of Δ9-tetrahydrocannabinol is limited by its psychoactive effects and predominant delivery route (smoking), as well as regulatory or legal constraints. However, other phytocannabinoids in combination, especially cannabidiol and β-caryophyllene, delivered by the oral route appear to be promising candidates for the treatment of chronic pain due to their high safety and low adverse effects profiles. This review will provide the reader with the foundational basic and clinical science linking the endocannabinoid system and the phytocannabinoids with their potentially therapeutic role in the management of chronic pain.
Chronic noncancer pain is common and use of opioids is increasing. Previously published guidelines on use of opioids for chronic noncancer pain have been based primarily on expert consensus due to ...lack of strong evidence. We conducted searches on Ovid MEDLINE and the Cochrane databases through July 2008 to identify studies that addressed one or more of 37 Key Questions that a multidisciplinary expert panel identified as important to be answered to generate evidence-based recommendations on the use of opioids for chronic noncancer pain. A total of 14 systematic reviews, 38 randomized trials not included in a previously published systematic review, and 13 other studies met inclusion criteria. Almost all of the randomized trials of opioids for chronic noncancer pain were short-term efficacy studies. Critical research gaps on use of opioids for chronic noncancer pain include: lack of effectiveness studies on long-term benefits and harms of opioids (including drug abuse, addiction, and diversion); insufficient evidence to draw strong conclusions about optimal approaches to risk stratification, monitoring, or initiation and titration of opioid therapy; and lack of evidence on the utility of informed consent and opioid management plans, the utility of opioid rotation, the benefits and harms specific to methadone or higher doses of opioids, and treatment of patients with chronic noncancer pain at higher risk for drug abuse or misuse.
Currently, clinical decisions regarding the use of opioids for chronic noncancer pain need to be made based on weak evidence. Research funding priorities need to be set to address these critical research needs if the care of patients with chronic noncancer pain is to improve.
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