“We must all die. But that I can save him from days of torture, that is what I feel as my great and ever new privilege. Pain is a more terrible lord of mankind than even death itself.”

— Albert Schweitzer, 1931¹

 

lbert Schweitzer rhetorically answered the question about the appropriate use of opioids some 70 years ago, so why the continued debate? Historically opioids have been and continue to be a primary means to treat patients suffering from all types of pain, especially chronic intractable pain. Who would know better the efficacy of opioids in chronic pain than the anesthesiologists who deal daily with these agents and who are the experts in opioid administration? To deny a patient with chronic pain the right to aggressive, clinically proven treatment using a combination of opioids as well as other pharmacologic, invasive and nonpharmacologic treatment in 2005 regimens is simply unforgivable and unacceptable. The argument against the proper use of opioids in chronic pain is debatably a nonargument, which flies in the face of scientifically proven, objective, rational treatment modalities for the chronic pain patient.

The American Medical Association (AMA) estimates that 75 million Americans experience chronic pain, and nearly one in 10 adults suffers from moderate to severe noncancer pain.² While there may be individuals who argue against opioid therapy as one or part of a regimen to treat chronic noncancer pain, there is no reasonable scientific or medical group that would deny the efficacy of aggressive treatment for this same group of patients using these medications, which are immediately available in various delivery forms. Opioids have been and will most probably always continue to be one mainstay therapeutic option available to fight the war on chronic pain. With the advent of long-acting opioid agents lasting in duration from eight hours to 72 hours, the roller-coaster effects of short-acting opioid agents have been all but eliminated, and steady state concentrations of opioids allow patients to achieve better pain control without the side effects traditionally associated with short-acting agents.

New Interest in Pain
The last couple of decades have shown tremendous interest on the part of physicians, patients, insurers, law enforcement officials and legislators to affect the practice of pain medicine in the United States. Since the publication of the U.S. Department of Health and Human Services clinical practice guidelines “Acute Pain Management: Operative or Medical Procedures and Trauma”³ in 1992 as well as the 1994 guidelines “Management of Cancer Pain,”⁴ the treatment of pain has been emphasized, and opinion overwhelmingly remains that the use of opioids is the gold-standard, pharmacologic mainstay of treating pain.

Since the beginning of time, humankind has relied upon derivations of opium to treat pain and alleviate suffering. The nondisputed usage of opioid analgesics in cancer and acute pain has led to much discussion and research for their role in noncancer chronic pain states as well. Many studies, including those from Portenoy, Foley, Moulin, Roth and Zenz, have shown the efficacy of opioids in chronic noncancer pain.^5-9 Some of those clinicians who debate the necessity of transdermal or oral opioids in chronic pain admit to the essential nature of opioids in this class of patients by arguing for the intrathecal or epidural administration of these agents as solo or adjuvant therapeutic alternatives.¹⁰ Hence there is no argument for effective pain management that can totally exclude opioid analgesics.

The Arguments
Some will argue against opioids because of the associated side effects such as nausea, somnolence, respiratory depression, constipation and tolerance to the analgesic effect. Review of opioid pharmacology reveals that when used properly (dosage, duration, forms administered) and for appropriate reasons, they are agents of extremely low toxicity.⁵ In fact Portenoy notes that in carefully selected patients with chronic pain, therapy with opioids can enhance comfort without causing intolerable side effects, functional deterioration or aberrant drug-related behaviors.⁵ The argument that tolerance to the analgesic effect of opioids occurs rapidly has been addressed critically in the literature. Since opioids are rarely the only agent used in managing chronic pain (usually, and most effectively, they are one of several agents employed), it has been shown that unlike the marked tolerance found in methadone maintenance patients, chronic pain patients may have “antitolerance mechanisms.”¹¹ Also the many distinct medications and the mechanisms of actions of other agents used simultaneously with opioids (N-methyl-D-aspartate antagonists, nitric oxide synthase inhibitors, Substance P antagonists, Calcitonin gene-related peptide antagonists, PKD inhibitors, calcium channel blockers and dynorphin antiserum) also may decrease the antinociceptive tolerance to opioids.¹²

Many physicians have a reluctance to prescribe opioid analgesics on a chronic basis because of the paucity of proper education and training about these medications. Unfortunately associated with the use of these medications are unfounded myths of addiction and abuse conditions which, when they do occur, are exceedingly rare. Granted, the abuse of opioids (as well as other prescription controlled substances) is on the rise in the United States, so caution must be taken when prescribing for chronic pain. This fear, however, cannot become rationale for arguing against the use of these effective medicines. Opioids are safe when used as prescribed, but in a small minority of patients, they can be addictive or deadly when taken inappropriately. Close monitoring of patients, extensive history-taking and compliance measures can greatly diminish any such aberrant behavior.13

Attention from the national media as well as from the legal system and state and federal regulatory agencies has caused the topic of chronic opioid use in noncancer chronic pain states to be debated by numerous persons and at multiple levels within the health care and legal systems. Many physicians hide from a true knowledge that opioid use is appropriate for their patients because of fear of disciplinary sanctions by state medical boards, judicial systems or the Drug Enforcement Administration (DEA). Fortunately intervention by these groups is extremely rare, especially when the physician follows well-accepted protocols for opioid prescribing. The DEA has stated, “It is crucial that physicians who are engaged in legitimate pain treatment not be discouraged …”¹⁴ The argument against opioids because of legal/regulatory fear also is unfounded. The pain practitioner practicing with proper documentation and safe prescribing habits is not going to be the victim.¹³

Virginia Guidelines
Since 1993, for example, the Commonwealth of Virginia has been aggressive in its advocacy of the proper treatment of chronic pain patients using opioids, developing guidelines for the use of opioids by physicians who treat patients for chronic noncancer pain.¹⁵ The Virginia guidelines were subsequently studied and modified by the Federation of State Medical Boards in 1998. The Federation “recognizes that … opioid analgesics may be essential for the treatment of … chronic pain whether due to cancer or noncancer origins.”¹⁶ Both the American Pain Society and the American Academy of Pain Medicine developed consensus statements about the need to effectively manage chronic pain using opioids shortly thereafter.¹⁷

While the argument for opioids as solo therapy in the management of chronic pain is akin to the argument of using only a diuretic in the treatment of hypertension — neither is in and of itself enough or effective — the argument to totally remove the opioid from the analgesic ladder of chronic pain is simply unfounded and bad medicine. Opioid therapy is the standard of care for acute, cancer and chronic pain patients. Careful selection of patients and continuous reassessment and monitoring of patients for compliance and treatment goals and outcomes is mandatory.

Treatment of chronic pain with opioid analgesics is almost always appropriate, but it must be remembered that with the abundance of pharmacologic and nonpharmacologic modalities available today, the practitioner must look at the pain patient in a multidimensional model. Ultimately, through careful history and thorough treatment with the use of opioids and other modalities, we can all come a bit closer to Dr. Schweitzer’s ideal.

References:
1. Schweitzer A. On the Edge of the Primeval Forest. New York: Macmillan, 1931:62.
2. Statement of the American Medical Association to the Subcommittee on Health, Committee on Energy and Commerce, U.S. House of Representatives: “Prescription Drug Monitoring: Strategies to Promote Treatment and Deter Prescription Drug Abuse,” March 4, 2004.
3. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, Clinical Practice Guideline for Acute Pain Management: Operative or Medical Procedures and Trauma, AHCPR Publication Number 92-0032. Rockville, MD: February 1992.
4. U.S. Department of Health and Human Services, Agency for Health Care Policy and Research, Clinical Practice Guideline Number 9: Management of Cancer Pain, AHCPR Publication Number 94-0592. Rockville, MD: March 1994.
5. Portenoy R. Opioid therapy for chronic nonmalignant pain: A review of the critical issues. J Pain Symptom Management.1996; 1:1203-1217.
6. Portenoy R, Foley K. Chronic use of opioids analgesics in non-malignant pain: Report of 38 cases. Pain. 1986; 25:171-186.
7. Moulin D, Iezzi A, et al. Randomised trial of oral morphine for chronic non-cancer pain. Lancet. 1996; 347:143-147.
8. Roth S, Fleischman, R, et al. Around-the-clock, controlled-release oxycodone therapy for osteoarthritis-related pain: Placebo-controlled trial and long-term evaluation. Arch Intern Med. 2000; 160:853-860.
9. Zenz M, Strumpf M, Tryba M. Long-term oral opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Management. 1992; 7:69-777.
10. Hassenbusch, S, et al. Polyanalgesic Consensus Conference 2003: An update on the management of pain by intraspinal drug delivery — Report of an expert panel. J Pain Symptom Management. 1992; 27:540-563.
11. Doverty M, et al. Pain. 2001; 93:155-163.
12. South, S, Smith, M. Pain: Clinical Updates 2001; IX, No. 5.
13. Cole BE. Prescribing opioids, relieving patient suffering and staying out of personal trouble with regulators. The Pain Practitioner. 2002; 12(3):5-8.
14. Federal Register. November 16, 2004 Volume 69, Number 220.
15. Long S. Preliminary report of ad hoc committee: Pain management. Virginia Medical Quarterly. 1997 Fall; 222-223.
16. West, J, Aronoff, G, Dahl J, et al. Model guidelines for the use of controlled substances for the treatment of pain. Federation of State Medical Boards of the United States, Inc. 1998.
17. A consensus statement from the American Academy of Pain Medicine and the American Pain Society. The use of opioids for the treatment of chronic pain. Special Supplement; Spring 1997:1-4.

Stephen P. Long, M.D., is Medical Director, Commonwealth Pain Specialists and Associate Professor of Clinical Anesthesiology, Virginia Commonwealth University, Richmond, Virginia.