Critical Transition from Short-to-Long-Acting Opioid Therapy
Hydrocodone-acetaminophen compounds (HCA) and other short-acting opioids are now among the most commonly prescribed drugs.1,2 This is indeed a tribute to physicians who have elevated treatment of pain problems in their practices to a position of prime importance—as it should be. In their current formulations, HCA compounds and other short-acting opioids have proved to be extremely versatile and effective. They are relatively safe and effective for practically any painful condition including musculo-skeletal maladies, headaches, and rheumatologic disorders.
Unfortunately, HCA and other commonly prescribed short-acting opioids—including codeine, meperidine, hydromorphone, and oxycodone-acetaminophen compounds—may not adequately control severe, chronic pain by themselves. The failure to control severe, chronic pain with short-acting opioids invariably occurs in a patient who complains of severe, constant, or persistent pain. Although the number of chronic pain patients in this category is not known precisely, they are grossly under-treated at this time. These patients experience flares or exacerbations that may last for a few hours or several days. Often the flare is referred to as breakthrough or rescue pain (see Table 1). Despite HCA or other short-acting opioid treatment, a long-acting opioid is indicated. A common tip-off to today’s practitioner is the patient who reports that six to eight separate dosages of HCA or other short-acting opioids a day aren’t enough to control pain. In addition, practitioners commonly encounter patients who exceed the safe daily acetaminophen dose of about 3500 to 4000mg a day.
Although the physician may recognize the clinical necessity of a long-acting opioid, the morbidity and mortality associated with initiation of long-acting opioids has proved a medical hazard. The nation has recently experienced an epidemic of deaths associated with the use of the long-acting opioids oxycodone and metha-done. I have recently reviewed numerous cases of death where a physician attempted to transfer a patient from HCA or other short-acting opioids to long-acting opioids (see Table 2).
These deaths have resulted in numerous malpractice and product liability lawsuits. In these cases, the physician almost always attempted to totally substitute a long-acting opioid for a short-acting opioid. Often the physician attempted to follow one of the typical published opioid conversion tables.
Immediate and total substitution of a long-acting opioid for HCA or other short-acting opioid is hazardous and should rarely be done. This article describes my method of initiation of a long-acting opioid in patients who are currently using a short-acting opioid with ancillary medication such as benzodiazepines, muscle relaxants, and anti-depressants. I estimate having used this procedure on over 1,000 chronic pain patients over a 30-year period, and have never experienced a death in my practice.
Simple Method to Initiate Long-Acting Opioids
My method to initiate long-acting opioid therapy is simple (see Table 3#). Rather than stop HCA, meperidine, or other short-acting opioid, merely continue the short-acting and add a low dose of long-acting opioid to the regimen. Leave the patient on this low dose for 72 or more hours to insure that there is no drug interaction, over-sedation, drug sensitivity, or allergic reaction. If there is no adverse event in this 72 hour period, titrate the dosage of long-acting opioid upward to increase pain control over the next six to twelve weeks. Allow the patient to continue HCA or other short-acting opioids on an as-needed basis for breakthrough pain or flares. The patient is instructed to only reduce or stop their short-acting opioids and ancillary medications on a schedule that provides them maximal pain relief.
By this method, severe chronic pain patients will, over a period of six to twelve weeks, settle on a quite stable regimen of a combination of long and short-acting opioids and ancillary medications. Patients treated by this method achieve significantly better pain control and enhance their physical, mental, social, and vocational status. I have now followed 20 of these patients for over 20 years.
Physiologic Basis For Methodology
There are two basic types of chronic pain: intermittent and constant. Intermittent pain is the most common form of chronic pain and encompasses headaches and musculo-skeletal disorders. The constant form is permanent and is characterized by existing biological manifestation (e.g. neurologic defect) that produces constant pain. While some flares or breakthrough episodes appear to be precipitated by such events as intentional movement, stress, or concomitant illness, others have no discernable etiology. To control constant pain caused by permanent neurologic defect, a critical blood level of opioid must be maintained at all times including sleep-time. A physician who attempts to control constant, baseline pain with short-acting opioids may witness their patient escalating their dosage—often to unsafe levels. In addition, patients may attempt to use ancillary medications including benzodiazepines, muscle relaxants, anti-inflammatory agents, anti-depressants, and even alcohol or illegal drugs in an effort to control their pain. The clinical picture may falsely appear as if the patient is randomly abusing medication when, in reality, the patient needs a long-acting opioid to suppress the baseline pain. Once baseline pain is adequately-controlled, one can then reduce the use of short-acting opioids and ancillary medications. Patients who compulsively seek relief in the face of poorly-controlled pain are referred to as pseudoaddicts.
“Due to this safety fact, long-acting opioids, in the opinion of this author, should never be prescribed to opioid naive patients until short-acting opioids prove inadequate.”
The Methadone Maintenance Model
My method of initiating a long-acting opioid is patterned after the model used in methadone maintenance clinics which treat heroin addicts. In these clinics, the starting methadone dose is 20 to 40mg a day. Over 60 to 90 days the daily dosage is progressively raised to a maximum of about 100-180mg a day.
Why is the first day dose so low? Simple. The heroin addict is known to concomitantly use benzodiazepines, alcohol, marijuana, and multitudes of other drugs. Additionally, his tolerance is incompletely known and subject to a variety of factors such as daily opioid dose, longevity of use, gastrointestinal absorption, and liver disease. The first methadone dose is given orally in front of a nurse or physician, and the patient must wait 30 minutes to be sure an anaphylactic or other adverse reaction doesn’t occur. Over 100,000 heroin addicts are treated each day in methadone maintenance clinics across the country. These clinics have been in existence since 1965. Their safety record has been remarkable considering that heroin addicts are far less compliance-prone than the average pain patient. In these clinics, the method of beginning the long-acting opioid, methadone, at a low dose and titrating upward over a few weeks has resulted in almost negligible overdose deaths in the first month of treatment.