Pain Relief: Striking the Right Balance

JULY 01, 2008
Jeannette Y. Wick, RPh, MBA, FASCP

Ms. Wick is a senior clinical research pharmacist at the National Cancer Institute, National Institutes of Health, Bethesda, Maryland. The views expressed are those of the author and not those of any government agency.

Pain has received a considerable amount of attention since the Joint Commission encouraged health care providers to consider it the fifth vital sign. Treating acute pain is quite straightforward. When pain becomes chronic, providing optimal pain management requires a fine balance between the patient's needs and beliefs, analgesic availability, clinician skill, and the law.

Most pharmacists are familiar with the World Health Organization's pain ladder, which indicates that mild pain should be treated with OTC drugs or prescription-strength nonsteroidal anti-inflammatory drugs (NSAIDs) with or without adjuvant treatments (antidepressants, anticonvulsants, etc). If pain is of moderate intensity, stepping up to an opioid suitable for moderate pain, with or without a nonopioid analgesic and adjuvants, is appropriate. The final step—severe pain—is treated with the strongest of the opioids, again, with or without additional nonopioids or adjuvant treatments. Clinicians should schedule round-the-clock analgesics and encourage patients to adhere to therapy. This model was developed for chronic malignant pain. At each step, other modalities (eg, psychological therapy and rehabilitative therapies) can help improve function and ensure that patients accrue maximum benefit from analgesics.

In the past, pain experts could not agree on a model addressing chronic nonmalignant pain. Today, a few controlled studies and many uncontrolled studies validate opioid use in chronic nonmalignant pain.1-7 Opioids provide effective analgesia with acceptable side effects in a wide range of chronic nonmalignant pain conditions.8,9 Many clinicians and patients still avoid opioids, however, as myths and misconceptions about the medicines persist. They often have concerns about addiction, intolerable and potentially dangerous side effects, and functional deterioration.10,11 Regulatory scrutiny also is a concern for clinicians.11

The treatment goal for chronic nonmalignant pain is to relieve the pain and improve function.7 Complete pain relief may not be achievable or realistic (and this is a key point that patients and clinicians must understand), but improved functioning usually is. Prescribers who treat patients with chronic pain usually develop specific goals for functional improvement with individual patients.12,13 These may be as simple as, "The patient will be able to garden for 1 hour by the end of the week," and pharmacists can ask patients if they understand what their specific functional goals are.

When the patient takes aspirin, acetaminophen, or NSAIDs regularly, counseling should begin with inquiring about the dose and dosing schedule if the analgesic is OTC. In addition, ask the patient about aspirin allergies and allergies to other pain relievers. Scan the patient's profile for anticoagulants, and ask about any history of gastrointestinal (GI) bleeding or ulcers. Patients who have liver disease, or those who consume 3 or more alcoholic beverages a day, should avoid acetaminophen. It is prudent to remind patients that many OTC and prescription pain medicines contain acetaminophen; they need to read labels carefully, so they do not approach or exceed the maximum daily dose (4 g/day for adults; 2.4 g/day for seniors and people with hepatic impairment).

Many NSAIDs are available in both OTC and prescription forms, which often confuses patients. If they receive a prescription-strength NSAID, explain that it is stronger than the OTC version, and also tell them what brand and generic names are the same medication. The FDA has revised labeling for all prescription NSAIDs to include a boxed warning stressing the potential for increased risk of adverse cardiovascular events.14 In addition, patients also need to be aware that the risk of GI bleeding is well established, and they should know what signs to watch for. Dose reductions may be necessary if they have renal impairment. Should patients need to step up to opioid relief, pharmacists will need to ask them about their beliefs and concerns. Patients who fear addiction (an unpredictable, compulsive, psychological craving for euphoria that appears in 10% to 20% of the population) will need to understand its difference from abuse and dependence. Adhering to medications as prescribed prevents abuse. Physical dependence is predictable, and patients usually develop some degree of physical dependence after receiving opioids regularly for more than 5 to 7 days. Patients who take opioids chronically for pain will experience withdrawal if they stop them abruptly, reduce their dose too quickly, or receive an opioid antagonist. If treatment must be discontinued, using a tapering regimen helps to avoid withdrawal.15

Sometimes, explaining that a similar phenomenon can occur with the chronic use of many classes of medications— including nitro vasodilator therapy, α2-adrenergic agents, corticosteroids, and antidepressants—helps take away some of the trepidation.16 Avoid using stigmatizing terms, such as "addiction" and "detoxification," to describe patients who are physically dependent on opioids. 16 Opioid use for pain management is seldom associated with the development of addiction, unless a patient has a predisposition to substance abuse prior to opioid therapy.1,15,17 Pseudoaddiction is a term used to describe behavior that may occur when pain is undertreated, but this condition is beyond the scope of this article.15,16,18

Tolerance to opioids' desired (analgesic) and undesired (adverse) effects will develop, but rates vary among patients.19,20 Tolerance predictably creates the need for more frequent doses, or increasing doses, to achieve the same effect.21,22 Tolerance does not indicate addiction.23 This differential rate of development explains the safe use of large doses of opioids in patients without causing respiratory depression.20,22 If tolerance to analgesia develops, it often develops slowly.

To delay the development of tolerance, clinicians often combine opioids with nonopioids or adjunctive therapy, which enhances analgesia.

Side effects cause nonadherence more often than tolerance to analgesia does. Counseling patients that certain side effects will lessen with time is imperative (Table).

Chronic pain can be treated successfully as long as the patient and all members of the health care team recognize that a goal of a completely pain-free existence may be unreasonable. Additionally, if treatment includes opioids, every member of the team needs to stress proper adherence, meaning that neither overadherence nor underadherence is acceptable. Sadly, it also means paying careful attention to record keeping, in the event that the regulatory agency has questions. Perhaps some day, we will have drugs that provide pain relief without the shadow of abuse and addiction complicating prescribing.

Table 2
Tolerance to Opioid Side Effects

Side Effect

Counseling Point

Cognitive: sedation, confusion, mood changes and sensory changes (eg, visual and auditory illusion, hallucinations, and delirium)

• Cognitive effects usually occur during the first 2 weeks of therapy or following a dose increase, although tolerance to these effects usually develops rapidly
• Opioid-dependent patients (ie, those stabilized on longterm opioid therapy) may retain driving skills
• The greatest potential impairment occurs during the first few days of use and during the first few hours after a dose change

Nausea and vomiting

• In most patients, tolerance develops during the first week of therapy
• Prophylactic antiemetics may be needed in patients with a history of motion sickness or severe opioid-induced nausea

Constipation: a reduction in bowel movement frequency to less than 1 every 3 days, or difficulty passing stool

• Tolerance to the GI effects of opioids develops very slowly, if at all. Constipation is likely to persist in most patients
• Prophylactic use of stimulating cathartic drugs (eg, bisacodyl, senna), with the addition of stool softeners, particularly in the elderly or in patients with coexisting GI pathology, is crucial
• Encourage increased fluid and dietary fiber intake

Respiratory depression

• Rare when the opioid dose is carefully titrated to the patient's pain
• If clinically significant respiratory depression occurs, administer opioid antagonists, titrated carefully to prevent opioid withdrawal symptoms

GI = gastrointestinal.
Adapted from references 5, 15, 19, and 23-36.


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