I was surprised since mostly chronic pain patients end up on opioids like oxycontin, oxycodone, hydrocodone, fentanyl.
STORY OF THE WEEK
Chronic Pain and Use of Opioids
Research · March 14, 2014
TAKE-HOME MESSAGE
In this cohort study, 85% of over 14,000 patients who reported chronic nonmalignant pain did not use opioids. Occasional and persistent use was reported in 12% and 3% of patients, respectively. In addition, about 75% of patients who did use opioids reported that their pain was still strong or very strong.
The authors conclude that many patients with chronic nonmalignant pain do not use opioids, and a majority of those who do use opioids do not experience pain relief.
1 Expert Comment
Primary Care
Robert Bonakdar MD, FAAFP
The present study conducted in Norway attempted to answer several important questions including who is using opioids for pain, whether opioids seem to reduce incidence of severe pain, and which factors influence persistent use of opioids. Although a number of limitations are associated with doing these types of studies, most of the patients utilizing chronic opioid therapy had the most severe pain in spite of treatment. This brings up several questions, including whether these patients were adequately treated and whether they were continuing to receive benefit from treatment.
From a research perspective, this study points to the need for additional prospective trials using predictive models of comorbidities, genetics, activity level, and polypharmacy to determine how opioids may affect the end goal of improved function and quality of life with various treatments. Unfortunately we have minimal evidence to point us in the right direction and even less evidence to let us know when to reevaluate or de-prescribe. Some preliminary research does show that, in the right scenario, reducing opioid dose may actually reduce pain and depression and improve functional status. However, clinically, as with any chronic pain scenario, it is important to re-evaluate ongoing treatments to determine their benefit. Working with patients to attempt therapeutic trials with reduction of therapies—especially passive therapies—can, in some cases, provide surprising results while helping to simplify the regimen for provider and patient.
ABSTRACT
In previous studies on prescription patterns of opioids accurate data on pain are missing, and previous epidemiological studies of pain lack accurate data on opioid use. The present linkage study which investigates the relationship between pain and opioid use is based on accurate individual data from the complete national Norwegian prescription database and the Nord-Trøndelag health study 3 which includes about 46 000 persons. Baseline data were collected in 2006 to 2008 and the cohort was followed for three years. Of 14 477 persons who reported chronic non-malignant pain 85% did not use opioids at all, while 3% used opioids persistently and 12% occasionally. Even in the group reporting severe or very severe chronic pain the number not using opioids (2680) was far higher than the number who used opioids persistently (304). However, three quarters of persons using opioids persistently reported strong or very strong pain in spite of the medication. Risk factors for persons with chronic pain who were not persistent opioid users at baseline, to use opioids persistently three years later were occasional use of opioids, prescription of >100 defined daily doses/year of benzodiazepines, physical inactivity, reports of “strong” pain intensity, and prescription of drugs from eight or more ATC groups. The study demonstrated that most persons having chronic non-malignant pain are not using opioids, even if the pain is strong or very strong. However, the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment.
Pain
Chronic Pain and Use of Opioids: A Population Based Pharmacoepidemiological Study From the Norwegian Prescription Database and the Nord-Trøndelag Health Study (HUNT)
Journal–Pain 2014 Mar 14;[EPub Ahead of Print], OM Fredheim, M Mahic, S Skurtveit, O Dale, P Romundstad, PC Borchgrevink
From MEDLINE®/PubMed®, a database of the U.S. National
There are at least two persistent, not-easily-solvable problems with research into this field, and one in particular that I see with this study.
#1) Pain tolerance & perception vary significantly between individuals.
A number of studies have been done showing that Olympic & professional athletes (among others) typically experience pain differently than the average population does. This is not to say that they do not feel pain at all, but rather that while they perceive injury &/or discomfort, the pain signifying such tends to not be debilitating or overwhelming, possibly due to training, neuro-chemical differences, or even physiological differences in the nervous system.
In addition, it is normal for many people to become accustomed to minor aches and pains that happen through the normal course of living. As one ages, those aches and pains may become more pronounced. However, if one prefers to eschew medication in favor of “toughing it out,” it is quite possible for such a one to end up with a much higher tolerance for pain. How many times have each of us here thought “Eh, I have a headache, but it’s not TOO bad, I’ll go get the Advil later…” only to never actually end up taking any? The same phenomenon exists at higher levels of discomfort as well; as one commentator on a documentary I watched recently put it, “You can get used to anything!” (He was speaking of the London Blitz of WWII, just fyi.) To such a person, a broken leg might be “uncomfortable,” while the same injury might be “debilitating agony” to someone else.
The bottom line here is that trying to get an objective baseline of pain threshold, tolerance, and relief is like trying to saddle a horse without roping it first: theoretically it might be possible, I’ll just be over here watching you from a safe distance w/the EMTs on speed-dial…
#2) In most cases, pain medications don’t actually treat the disorders causing the pain.
Since pain relief is all that these drugs accomplish with any degree of certainty, the natural result is that when the drugs wear off, the pain comes back — possibly all the more intensely from the perspective of the patient who has just experienced a period of significant relief (see #1 above). It’s also entirely possible that those who experience the most complete relief of pain end up engaging in activities which (once the meds wear off) exacerbate the conditions causing the pain in the first place.
Finally, my problem with this study is its #3) Definition of terms.
When I had my wisdon teeth out (all 4, plus one damaged molar, gratis), I left the office conscious, but under the influence: I was drowzy, less than 100% coherent, but I felt no pain or discomfort at all. I was told to take 2 Percocet at 8hr intervals for the first day, then 1 every 8hrs the next few days. After that I was to take 1 as needed, but no more than 1 per 8hrs. I took the first dose on schedule, before any real pain or even discomfort could set in… and passed out.
12 hours later — four hours after my next scheduled dose, for those keeping score at home — I woke up to ridiculous amounts of pain. The next dose countered the pain imperfectly, but the dose after that (taken ON schedule) took care of it, and I was fine from that point on.
In the study at hand, they say that “the vast majority of patients with persistent opioid use report strong or very strong pain in spite of opioid treatment.” Granted, they mention that they studied “chronic” pain, not the sincerely acute stuff of my anecdote. But my question remains: did the study find that the subjects experienced the reported pain even during the time their drugs were supposed to be working? Or does it mean that once the drug wore off the pain returned at “strong to very strong levels” (as in my story above)? We do not know from the description provided. Because of this, the study is of minimal use.
My personal take away from this study is that patients who treat their pain — with opioids or anything else — are TREATING their pain, not curing it. This I think we could have told the authors ourselves, had they but asked, no study required. What the study authors wanted to cover was whether opioids work better than other pain relief options. However, I don’t think we can tell from this effort.
I self medicate every day for pain with a gin and tonic…….works.