Use of Opioids in Nonmalignant Pain

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Treatment with an opioid in nonmalignant pain of noncancer origin (i.e., pain due to rheumatic disorders, pain in chronic degenerative osteoarthritis) still is judged controversial [89-92]. While in acute pain states and in cancer pain, pathophysiology and assessment are better understood, and the use of opioids are a well-accepted standard of care. Presently there is no consensus regarding treatment modalities or the role of opioid analgesics for the treatment of patients who suffer from pain of nonmalignant origin. It generally is accepted however, that opioid therapy for nonmalignant pain is indicated if all other conventional, established pain-related interventions have failed. If this is the case, similar as in cancer-related pain therapy, opioid therapy in nonmalignant pain is characterized by the following:

• pain medication is given in a fixed time pattern (dosing by the clock);

• continuous surveillance in order to adjust the medication by either an increase or by a reduction of the dose;

• need for an opioid is derived from pain intensity and not the diagnosis;

• at start of the therapy, an opioid of low to medium potency is selected;

• opioid therapy is embedded into a parallel medication with other non-opioid analgesics;

• simultaneously with opioid therapy start the prophylactic medication for constipation;

• when considering opioids for chronic nonmalignant pain, rather than short-acting agents, long-acting formulations are recommended.

The latter is of major importance as short-acting opioids encourage a pattern of frequent dosing that increases the risk of both tolerance and abuse, while long-acting opioids are less likely to provide euphoric effects.

In chronic non-malignant pain it is necessary to evaluate whether a psychosomatic origin is not the crucial determinant for chronification. It therefore is necessary to exclude any type of psychosomatic pain from opioid therapy, since such patients are not appropriate candidates for opioid therapy since they demonstrate a potential development of tolerance, dependency, the illicit use and misadventure. Development of psychoreactive pain has to be assumed whenever the patient describes his/her pain syndrome while consulting family members, describing his/her complaints, and where a morphologic substrate is not or ever was present. The following points have to be recognized in chronic non-malignant pain in order to reason the use of opioid therapy:

1. Search for the cause of pain of non-malignant origin.

2. Previous unsuccessful conventional pain therapy using NSAIDs, COX-2 inhibitors or TCAs.

3. The otherwise therapy-resistant pain due to a benign disease.

4. Intense pain associated with degenerative joint disease.

Only when all prerequisites for opioid therapy in nonmalignant pain are fulfilled, then the risk for the development of abuse and dependency is practically non existent.

In summary, opioids in nonmalignant pain are only indicated when patients present a psychosocial stable environment and where previous treatment was ineffective. Just as pharmacological pain control will have limited benefits if it is not combined with a rehabilitation program, the opioid is likely to be ineffective, if pain interferes with compliance [93]. Pain-related non-malignant pathologies that possibly can result in the relief by an opioid are:

1. Severe osteoarthritis (OA) and cartilage distruction

2. Severe rheumatoid arthritis (RA)

3. Exessive generalized osteoporosis

4. Stenosis of the spinal canal

5. Degenerative disease of the vertebral column

6. Phantom limb pain

7. Central pain syndrome following stroke (thalamic mediated pain)

8. Postnucleotomy syndrome following failed back surgery

9. Postherpetic neuralgia (PHN)

10. Neuropathic pain when combined with co-analgesics

Opioids however, are contraindicated in patients with the following non-malignant pain-related conditions:

1. Trigeminal neuralgia

2. Migraine or chronic tension type headache

3. Functional intestinal pain

4. Functional urogenital pain

5. Crohn's disease

6. History of substances abuse

7. The patient with psychogenic or somatotopic pain

8. Absence of psychosocial stability of the patient

9. Insufficient control of effectiveness by the prescribing physician 10. The patient not signing an informed consent

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