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Articles  |   September 2007
Using Opioids for Patients With Moderate to Severe Pain
Author Notes
  • From the Phoenix Indian Medical Center, Indian Health Service, United States Public Health Service, where Mr Rasor is a volunteer. Mr Rasor is a fourth-year osteopathic medical student at Midwestern University/Arizona College of Osteopathic Medicine in Glendale; he participates in the Hoop of Learning programs that encourage Native American youth to pursue careers in healthcare. Dr Harris is in private practice in Sun City, Ariz, where he is an attending physician at the Walter O'Boswell Memorial Hospital, where he specializes in outpatient opiate addiction. 
  • Correspondence to Joseph Rasor, PT, OMS IV, Administration, Phoenix Indian Medical Center, 4212 N 16th St, Phoenix, AZ 85016-5319. E-mail: joe.rasor@cox.net 
Article Information
Pain Management/Palliative Care / Opioids
Articles   |   September 2007
Using Opioids for Patients With Moderate to Severe Pain
The Journal of the American Osteopathic Association, September 2007, Vol. 107, ES4-ES10. doi:
The Journal of the American Osteopathic Association, September 2007, Vol. 107, ES4-ES10. doi:
Abstract

In the United States, many visits to physician offices are for complaints of pain. Patients who have moderate to severe pain can be effectively treated with different modalities, including opioids. Proper management requires that physicians be open-minded and thorough. Physicians should take a complete history and perform a complete physical evaluation including an osteopathic structural examination to develop a comprehensive treatment plan. This strategy should include follow-up visits for continued assessment of therapy. Continued reassessment of treatment and patient responsiveness have been shown to be most beneficial to both physician and patient. Using the osteopathic medical model of treatment, physicians should identify psychosocial as well as somatic dysfunctions and appropriately treat patients for them. They should not avoid prescribing opioids because of fear of a patient's becoming addicted, but instead, integrate the use of such important analgesics in a multidisciplinary treatment plan. However, it must be recognized that opioids are powerful medications that require monitoring and dosing according to patient response.

Annually, more than 80 million Americans have serious pain, with approximately 86% having such discomfort on a chronic basis1; most common disorders are headache, lower back pain, arthritis, and other joint pain2); 25 million experience this condition acutely. Pain accounts for an estimated $61.2 billion in lost productive time annually; 76.6% of that cost is attributed to poor health-related performance while at work.3 
Pain is the second leading cause to be absent from work with the common cold being the first, and pain is the second leading cause for a person to seek medical care.4 Common pain complaints such as back pain, headache, arthritis, joint pain, and other musculoskeletal pains were found to account for 13% of the total workforce's losing productive time within a 2-week period.3 
Adequate treatment is necessary to allow patients to have a meaningful and productive life. Opioid use for pain management allows successful restoration of this ability. Thus, this article examines opioid use for effective analgesic therapy in patients with moderate to severe pain. 
Use of Opioids for Pain Control
Opioids can be traced back 8000 years to a Sumerian ideogram of hul gil, the “plant of joy.” Throughout history, opioids have been found useful in the treatment of multiple ailments. In the early 1900s, opioids became a controlled substance to be prescribed for medicinal reasons only; it could not be prescribed to addicts. Throughout the 20th century, control became tighter with the 1970 Federal Controlled Substance Act,5 which increased the monitoring of opioids and other controlled substances, and required registration of all prescribers. In certain contexts, this social move regulating medical practice and criminalizing the prescribing of these controlled substances created problems. Legal ramifications led to undertreatment of patients with pain, illegal opioid trafficking, and addiction. 
With continued education of healthcare providers, modifications in healthcare policy, consistency in management, and assessment in patient care, the emphasis on opioids as a legal issue shifted to a focus on medical management approaches.6 
Clinical Evaluation With Pain Assessment
To understand and effectively treat patients in pain, physicians must do a comprehensive evaluation that includes history, severity of pain, quality of life, and physical examination. Physicians should obtain and record a comprehensive medical, surgical, and family history, as well as information relative to prior pain treatment modalities and their effectiveness. Necessary documentation includes a complete list of current and past medications, including over-the-counter medications and supplements, as well as a history of alcohol, tobacco, and illicit drug consumptions. Physicians should also query patients to ascertain if they understand their dysfunction and their prognosis.6 
Figure 1.
Faces and visual analog scale for patient's self-assessment of pain.
Figure 1.
Faces and visual analog scale for patient's self-assessment of pain.
Figure 2.
Components of paradigm for treatment of patients with pain.
Figure 2.
Components of paradigm for treatment of patients with pain.
When patients are viewed as part of the treatment plan, they develop a greater understanding of their pain. They then are able to discriminate and characterize their pain at a more knowledgeable level, thus assisting physicians to obtain increased understanding of how the designed therapy benefits their patients. Patients should describe pain in their words and designate the location by use of a diagram or illustration. They should describe the onset, history, and pattern of pain over time. Use of a visual analog scale (Figure 1) allows documentation of the patient's pain at each visit for future comparisons. Patients should describe associated factors that relieve or exacerbate this discomfort.6 
Physicians must identify the impairment and how pain is adversely affecting various aspects of a patient's quality of life. Patients should evaluate their physical and psychosocial well-being, and also develop an understanding of how pain is adversely affecting their roles as an employee, spouse, parent, and human being. Physicians should take into account a patient's spiritual/religious beliefs so they can be aware of how the disease process relates to these important factors. Physicians should help patients understand how their ailment can affect their financial status (eg, cost of medicines, visits for medical care and lost wages).5 These characteristics are strongly tied to the success of a program and give subjective and objective measures by which physicians can document progress.7 
Physicians must establish the treatment goal for each patient with pain and know what the patient expects. It is important for physicians to relate realistic goals to their patients, thus offering opportunity to them for patient education on treatment and improved chance of success, as well as increased patient compliance and ownership of their problem. 
Figure 3.
Definitions denoting differences between physical dependence, tolerance, and addiction.
Figure 3.
Definitions denoting differences between physical dependence, tolerance, and addiction.
A physical examination evaluating all systems, active and passive range of motion, strength testing, neurologic testing, and structural and postural assessment should be included in the initial assessment.8 Documenting objective findings allows comparison at follow-up visits to assess improvement or failure with the treatment plan. Applying the osteopathic model addresses the entire physical and spiritual being as a whole, allowing for the diagnosis of a somatic dysfunction.9 Figure 2 outlines the paradigm of treatment of patients with pain. 
Treatment With Opioids
When using opioids in the treatment of patients in pain, the treatment plan should be comprehensive, including: 
  • selection and use of the appropriate opioid,
  • involvement of other healthcare providers, as warranted,
  • osteopathic manipulative treatment (OMT), as appropriate, and
  • patient education.
Administration of opioids for pain control has been shown to be effective for improving pain control and quality of life. They are powerful analgesics that can produce life-threatening toxicities; therefore, both physician and patient should carefully evaluate the risk-to-benefit profile of opioids.10 
It is well documented that clear differences exist between physical dependence, tolerance, and addiction (Figure 3). Tolerance occurs when the body adapts to the daily dose of the drug such that the pharmacologic effect is reduced; consequently, the patient requires an increased dose of the drug to achieve the desired therapeutic action. Physical dependence is a more significant clinical adaptation such that withdrawal reactions would occur on decreasing the dose. Addiction is a behavioral response whereby a person, despite adverse consequences, acts on compulsion to obtain and consume a drug. Undertreatment for pain may lead to a patient's drug-seeking behaviors to self-medicate.11,12 
Physicians are concerned about their patients' becoming addicted when using opioids for pain management. It was found that when physicians prescribe opioid therapy for patients with chronic cancer pain, with no drug abuse history, they have confidence that 75% of these patients will not become addicted. In contrast, when these same physicians are prescribing opioid therapy for patients with noncancer pain, with a history of drug abuse, they have a confidence level that 3% of these patients will not become addicted.11. The fact is that only between 3.2% and 18.9% of patients with a prior history of addictive behavior become psychologically dependent, a prevalence rate approximating that of the general population without a history of addiction. Furthermore, for patients with no history of drug abuse for whom opioid medication was prescribed for pain, the prevalence of drug addiction drops to less than 1%.12 
An understanding should be made between patient and physician that the patient's powerful pain medication is for his or her use only, and it is to be taken as agreed on by these two parties. Such an understanding should be written as a contract or an agreement and signed by both persons (Figure 4). It is essential that there be one prescribing physician and one pharmacy to avoid the potential for error or diversion, or both. 
Initial therapy should be with the lowest effective dose possible to minimize pain and medication side effects and to maximize the quality of life. The only limiting factor is patient response. Therefore, it is necessary to titrate dosage. 
Selection of the proper opioid (Figure 5) is crucial. Opioid dosing and conversion are complex procedures, as indicated by three Web sites.13-15 The greater the affinity of the opioid at the μ receptor, the greater the analgesic effect or potency.10 Opioids have pharmacokinetic differences in bioavailability, such as morphine, which is the standard, compared with fentanyl, which is 50 times as potent. Scheduled dosing is more effective at pain control and improving quality of life.16 
Combining sustained-release and immediate-release dosage forms has been shown to be effective.16 Additionally, having “rescue” or “breakthrough” medication (ie, immediate-release) allows the patient in periods of aggravated pain to increase the dose in minor steps to provide adequate analgesia.17,18 For example, a typical patient would have scheduled sustained-released dosing every 12 hours and scheduled immediate-release dosing every 6 hours, with breakthrough medication as needed with a previously discussed total number per day. 
Follow-up visits and continued monitoring are crucial for success and proper management of pain. These interactions ensure constant communication, patient coordination, patient support, and opportunities for education and proper adjustments to medication. Visits should be scheduled every 2 weeks for the first 2 to 4 months, then once a month.6 Pain medication should be prescribed at each office visit, with the dosage adjusted as needed based on patient reports of pain, use of rescue dosing, and quality of life. Education should consist of goal setting and helping patients understand different measures in pain relief through reduction in pain, improvements in quality of life, and decreases in the need for rescue drugs.19 
Figure 4.
Typographically enhanced physician and patient pain contract. (Adapted from contract used at the Phoenix [Arizona] Indian Medical Center.) Image Not Available
Figure 4.
Typographically enhanced physician and patient pain contract. (Adapted from contract used at the Phoenix [Arizona] Indian Medical Center.) Image Not Available
Having a multidisciplinary team of healthcare professionals who coordinate their efforts has proven to be effective in the management of pain. Depending on the identified specific needs of the patient, the team approach could consist of physical and/or occupational therapy, psychologists, sclerotherapy, physiatrics, interventional anesthesia, and/or invasive procedures (singly or in combination).8 Compared with single treatment, multidisciplinary approaches have been shown to reduce pain by an additional 20% to 40%; such effects are maintained up to 2 years.7 Applying osteopathic medicine skills during office visits can aid in pain reduction. Improving postural and mechanical alignments, fascial strains, and tissue texture changes can be highly effective for pain management and the body's innate ability to heal, which is at the very foundation of osteopathic medicine.20 
When patients have improved significantly, it is vital that opioid medication not be discontinued abruptly to avoid their having withdrawal reactions. Their dosage must be tapered slowly, reducing the amount every 2 to 3 days.11 The following case vignette illustrates a multidisciplinary and opioid-tapering approach in a patient with severe pain. 
Case Presentation
Marcie, a 26-year-old Native American woman, is recovering from a trimaleolar fracture and subsequent open reduction with internal fixation (ORIF) on the right side. She has had a slow recovery, hampered by her obesity (BMI 42) and marginal muscle strength from lack of conditioning. Her ambulation is limited as she is continuing to use crutches for locomotion. Marcie has requested short-acting opioids during the past 2 months since her ORIF. She is now taking oxycodone hydrochloride, 10 mg, with acetaminophen, 650 mg, every 3 hours. Her osteopathic physician is concerned with the rising opioid load and lack of improvement in mobility and muscle strength. Her osteopathic physical examination reveals asymmetric thoracic and lumbar range of motion (ROM) with increased somatic dysfunction and pain perceptions. She has reported pain levels in her back at 8 on a scale of 0 to 10 (8/10) with some improvements with the opioids.  
When should the provider consider prescribing long-acting opioids? 
What other modalities should be incorporated in Marcie's care? 
The physician has good reason to be worried about Marcie's severe pain. Her discomfort is validated with the somatic dysfunctions and diminished ROM found on osteopathic physical examination. Acute pain treatment with opioids has moved Marcie's pain into a chronic state, and she has now developed opioid tolerance and physical dependency; she currently requires oxycodone hydrochloride, 10 mg every 3 hours with minimal relief from severe (8/10) pain. With proper history, education, and the controlled substance agreement between Marcie and her physician, she was given a long-acting opioid analgesic to be taken twice a day; oxycodone hydrochloride 10 mg, was used for breakthrough pain. After a few weeks with close follow-up, Marcie reported adequate pain control (2/10). She stated that her worst pain was 5/10, which responded to her breakthrough opioid analgesic. 
Marcie was referred to physical therapy with evaluation, education, gait training, body mechanics, stretching, and exercise prescribed. She was also evaluated by dietary services for nutritional counseling. Marcie has continued to improve, decreasing her use of 10-mg oxycodone hydrochloride, to 5 to 6 tablets per week. This taper was over 12 weeks. It is expected that as Marcie improves her physical and somatic dysfunctions, she will continue to be titrated off short-acting opioid analgesics and later from long-acting opioid analgesics, and ultimately transitioned to nonopioid modalities with continuation of physical medicine. 
Comment
Comprehensive history, assessment—including an osteopathic structural examination—management, and education assure success in reducing pain. These key elements decrease the known small risk of opioid abuse. Understanding the need for titration and opioid tolerance and awareness of the possible need to increase dosage over time are important concepts. Combined physician-patient effort, frequent reassessment, and patient understanding substantially reduce opioid abuse and enhance the ability to improve quality of life and pain reduction. Understanding differences between addiction (psychological and deviant behavioral condition) and physical dependence (related to compensatory changes at receptor level [quantity and/or affinity]) will improve physician comfort in prescribing opioid therapy. 
Figure 5.
Figure 5.
 This continuing medical education publication is supported by an educational grant from Purdue Pharma LP
 
 The views expressed are those of the authors and do not necessarily reflect the views of the Indian Health Service.
 
 Mr Rasor and Dr Harris have no conflicts of interest to disclose.
 
Pain in the Workplace—A 10-year Update of Ortho-McNeil's Survey on the Impact of Pain on the Workplace. Titusville, NJ: PriCara, Unit of Ortho-McNeil Pharmaceutical Inc;2006 .
National Center for Health Statistics. Health. United States, 2006 With Chartbook on Trends in the Health of Americans; Hyattsville, Md; 2006.
Stewart WF, Ricci JA, Chee E, Morganstein, Lipton R. Lost productive time and costs due to common pain conditions in the US workforce. JAMA. 2003;290:2443-2454.
Katz JN. Lumbar disc disorders and low-back pain: socioeconomic factors and consequences. J Bone Joint Surg Am. 2006;88(suppl 2):21-24
Fine PG, Portenoy RK. A Clinical Guide to Opioid Analgesia. Minneapolis, Minn: McGraw-Hill Companies;2004 .
Washington State Department of Labor and Industries. Guidelines for Outpatient Prescription of Oral Opioids for Injured Workers with Chronic, Noncancer Pain. Olympia, Wash: Washington State Department of Labor and Industries; 2002.
Gallagher RM. Rational integration of pharmacologic, behavioral, and rehabilitation strategies in the treatment of chronic pain. Am J Phys Med Rehabil. 2005;84(3 suppl):S64-S76.
Sanders SH, Harden N, Benson SE, Vicente PJ. Clinical practice guidelines for chronic non-malignant pain syndrome patients II: an evidence-based approach. J Back Musculoskel Rehabil. 1999;13:47-58.
Broekhuizen J, Dekker A, Warne D. Evaluation and treatment of chronic pain in the Native American patient. American College of Osteopathic Family Physicians CME Supplement. November/December 2004:1-7.
Quang-Cantagrel ND, Wallace MS, Magnuson SK. Opioid substitution to improve the effectiveness of chronic noncancer pain control: a chart review. Anesth Analg. 2000;90:933-937.
Weaver M, Schnoll S. Abuse liability in opioid therapy for pain treatment in patients with an addiction history. Clin J Pain. 2002;18(4 suppl): S61-S69.
Greenwald BD, Narcessian EJ, Pomeranz BA. Assessment of physiatrists' knowledge and perspectives on the use of opioids: review of basic concepts for managing chronic pain. Am J Phys Med Rehabil. 1999;78:408-415.
McCarberg BH, Barkin RL. Long-acting opioids for chronic pain: pharmacotherapeutic opportunities to enhance compliance, quality of life and analgesia. Am J Therap. 2001;8(3):181-186.
Bloodworth D. Issues in opioid management. Am J Phys Med Rehabil. 2005;84(3 suppl): S42-S55.
McCarberg BH. Treatment of breakthrough pain. Pain Med. Jan-Feb(2007). ;8(suppl 1):S8-S13.
Cohen MJ, Jasser S, Herron PD, Margolis CG. Ethical perspectives: opioid treatment of chronic pain in the context of addiction. Clin J Pain. 2002;18 (suppl):S99-S107.
Licciardone JC. The unique role of osteopathic physicians in treating patients with low back pain. J Am Osteopath Assoc. 2004;104(suppl 8):S13-S18. Available at: http://www.jaoa.org/cgi/content/full/104/11_suppl/13S. Accessed September 11, 2007.
Figure 1.
Faces and visual analog scale for patient's self-assessment of pain.
Figure 1.
Faces and visual analog scale for patient's self-assessment of pain.
Figure 2.
Components of paradigm for treatment of patients with pain.
Figure 2.
Components of paradigm for treatment of patients with pain.
Figure 3.
Definitions denoting differences between physical dependence, tolerance, and addiction.
Figure 3.
Definitions denoting differences between physical dependence, tolerance, and addiction.
Figure 4.
Typographically enhanced physician and patient pain contract. (Adapted from contract used at the Phoenix [Arizona] Indian Medical Center.) Image Not Available
Figure 4.
Typographically enhanced physician and patient pain contract. (Adapted from contract used at the Phoenix [Arizona] Indian Medical Center.) Image Not Available
Figure 5.
Figure 5.