Opioids Can Safely Ease Chronic Non-Malignant Pain

by Gretchen Henkel

SAN DIEGO, CA--Opioids have a place in the treatment of chronic nonmalignant pain, says James H. Sanders, Jr., MD, CMD, Medical Director of the Brian Center for Health and Rehabilitation in Brevard, NC. But prescribing these drugs for elderly patients with chronic pain requires careful diagnosis and constant monitoring in order to avoid abuses and severe side effects.

In his presentation, Opioid Nonmalignant Pain Treatment: What They Aren't Telling Us, at AMDA's 25th Anniversary Symposium here, Dr. Sanders, a geriatrician and former specialist in addiction medicine, pointed out the critical differences between acute or malignant pain and chronic nonmalignant pain. He also explored medical and cultural views of pain, suffering, and opioid use--and suggested ways in which opioids can be safely and appropriately used to treat the elderly throughout the continuum of long-term care.

Pain Differences

Most chronic pain in long-term care is related to arthritis and musculoskeletal problems, including degenerative joint disease, rheumatoid arthritis, low-back disorders, crystal-induced arthropathies, and vertebral compression fractures resulting from osteoporosis, according to AMDA's 1999 Clinical Practice Guideline, Chronic Pain Management in the Long-Term Care Setting.

Another common cause is nervous system damage or disease--for example, diabetic neuropathy, postherpetic neuralgia, and trigeminal or occipital neuralgia. Headaches, oral or dental pain, chronic leg cramps, peripheral vascular disease, post-stroke syndromes, immobility and contractures, and pressure ulcers may also be at the root of patients' chronic pain complaints.

Before attempting to treat chronic pain in elderly patients, Dr. Sanders said, geriatricians must recognize the differences between chronic and acute or malignant pain. With a chronic pain condition, pain signals may keep firing in the nervous system for months or years, even after the patient has recovered from the initial illness or injury. This may cause central nervous system sensitization, resulting in hyperalgesia (a lowered pain threshold), allodynia (perception of pain caused by usually nonpainful stimuli), or the spread of pain to areas not normally innervated by the impaired nerve. Treating such pain often requires a multidisciplinary approach.

Real Complaints

Furthermore, it's important to keep in mind that the patient's pain complaints are real, said Dr. Sanders during a pre-symposium interview from his office at Brevard Family Practice. This view is underscored in AMDA's clinical practice guidelines as well as those of the American Geriatrics Society (J Am Geriatr Soc 1998;46:635-651).

"Physicians, in the past, had a tendency to pay little attention to treatment of symptoms. We're so interested in diseases that we've thought the treatment of the disease would take care of symptoms like pain. But in chronic nonmalignant pain, treatment of the disease doesn't necessarily take care of the pain. We're becoming more cognizant of the fact that we need to relieve our patients of pain as much as we can."

Aggressive treatment with opioids is appropriate in alleviating acute or malignant pain, said Dr. Sanders. However, applying the same approach when prescribing medications for chronic nonmalignant pain may in some cases exacerbate a patient's condition.

Chronic nonmalignant pain can rarely be eliminated, he emphasized. Failure to recognize this fact often leads to overprescription of pain medications, including opioids. Physicians should be careful to recognize when their patients are dependent or addicted, and take steps to prevent their prescribing practices from exacerbating or complicating a patient's illness.

In addition, the laxatives used to counter the constipating side effects of opioids, notably milk of magnesia and senna, can themselves do damage when used for a long period of time. "Magnesium salts draw water into the colon, increasing the risk of electrolyte imbalance, dehydration, and fecal incontinence, and can cause magnesium poisoning. Long-term use of senna may cause neuronal degeneration within the myenteric plexus and ultimately worsen constipation," he noted.

Multiple Medications

In his practice, Dr. Sanders has treated patients whose condition deteriorated due to opioid overprescription. In one such case, that of a 64-year old woman, multiple medications, including morphine, risperidone, and lorazepam, had rendered her immobile, groggy, severely nauseous, and constipated. The patient's original complaint of pain from osteoporotic vertebral compression fractures had been treated with opioids. However, when she did not experience complete pain relief, her former physician increased the dosages until, at the time Dr. Sanders admitted her to the Brian Center, the dosage was morphine IV at a base rate of 20 mg per hour, a 5 mg bolus q15 minutes as needed, and a 75 mcg per hour fentanyl patch changed every 72 hours.

Dr. Sanders detailed this case in a recent JAMDA article (J Am Med Dir Assoc 2001;2:239-240), and described how he was able to take the patient off pain medications, benzodiazepines, and sedating antihistamines after six months. At that point she resumed walking and some activities of daily living, including cooking.

In the article's conclusion, Dr. Sanders took issue with the following statement from AMDA's chronic pain clinical guideline: "Because morphine has no ceiling effect, the dose can be increased until the desired analgesic effect is obtained or until side effects become intolerable" (AMDA Clinical Practice Guideline: Chronic Pain Management in the Long-Term Care Setting, p. 20).

This advice, Dr. Sanders wrote, "makes sense in acute pain control, but not in chronic nonmalignant pain."

In the following issue of JAMDA, his views drew both praise and criticism from readers. Paul Rousseau, MD, Associate Chief of Staff for Geriatrics and Extended Care at the VA Medical Center in Phoenix, AZ, wrote that "the use of opioids in chronic pain should not be condemned because of one case report." Dr. Sanders' patient still had pain when she was discharged ("I hurt all the time," she reportedly said), and Dr. Rousseau argues that the patient should have been given an analgesic, including a low-dose opioid carefully titrated according to clinical response and patient function.

In another letter to the editor, Paul J. Drinka, MD, CMD, Clinical Professor of Internal Medicine and Geriatrics at the University of Wisconsin-Madison, agreed that "the elimination of pain is seldom possible. In fact, the total elimination of chronic musculoskeletal pain is probably contraindicated. Some level of pain may serve a useful purpose to remind the individual to perform exercises and maintain postural alignment to minimize anatomic traction or impingement generating the pain." Instead of aggressive prescribing, Dr. Drinka argued for "aggressive monitoring" when using chronic narcotic therapy, in order to prevent a patient becoming bedfast.

Comprehensive Examination

As described in the AMDA guideline, a comprehensive history and physical examination must first be performed to identify the cause of chronic pain. A multidisciplinary approach to pain treatment, such as those found at pain clinics, may be useful in addressing the patient's complaints. Prayer or meditation can often aid chronic pain sufferers, said Dr. Sanders. Other cognitive/behavioral or physical therapies may also help.

When choosing a treatment regimen, the physician should pick a course that has a good chance of reducing pain and associated disability and suffering. Educating the patient and family members about the nature of chronic pain is also necessary. Dr. Sanders advises patients and physicians alike to "realize that the pain will probably not be completely eliminated, but that enough improvement should be possible to enhance the quality of life." Those improvements can facilitate increases in function, which often also contribute to a patient's well-being.

For a small percentage of patients, he said, opioids may be needed. For suggestions on ongoing evaluation and monitoring of these patients, see sidebar at right.

Caution Urged

"Pain is an emotional issue," Dr. Sanders stressed, a fact that often complicates its diagnosis and treatment. In the United States, the debate about treatment of nonmalignant pain becomes more emotionally charged when the issue of opioids is introduced.

Dr. Sanders has seen the pendulum of opinion on opioid prescription swing back and forth throughout his career. He has changed his own views about the use of opioids to treat pain. Nearly 14 years ago, he and his addiction medicine colleagues "saw a lot of abuse and problems [caused] by physicians prescribing these addictive drugs to patients who were already addicted." In light of these effects, "I felt it was better not to use them at all for chronic nonmalignant pain. I think that I was wrong. It is appropriate to use these drugs; you just need to be careful and do it properly."

Currently, some physicians who have conducted short-term studies of newer opioid preparations are "very enthusiastic and have been evangelists for prescribing these drugs. There have been some abuses; some patients have died of overdoses, because they use these drugs inappropriately and with other drugs and alcohol."

"What I'm trying to do," he added, "is to get to a happy medium, so that we are not prescribing until we get unreasonable side effects." On the other hand, he concluded "we don't want to just not use these drugs--which are good drugs--because of fear of problems."

Medical journalist Gretchen Henkel is a Contributing Writer to Caring.

back to top