Longitudinal Study of Long-term Opioid Patients
The general public has, in recent years, demanded improved pain care, including the use of opioid drugs. As a result of this demand, there have been implementation of laws and promulgation of regulations and guidelines that permit physicians to prescribe opioids for severe chronic pain. In fact, over the past 20 years, numerous laws and guidelines have been established throughout the USA to allow physicians to prescribe opioids for chronic pain patients who have non-malignant conditions.
Despite the energetic and forceful efforts to make opioids available for non-malignant pain treatment, there are almost no reports available on the outcome and merits of opioid therapy beyond about three years.1-4 Information regarding the long-term outcomes of opioid treatment is needed to determine if long-term, opioid therapy produces a quality life with acceptable risks, and if opioid treatment may lead to permanent reduction in pain.
In the 1970’s and early 80’s, this author participated in a pilot effort to begin treating chronic non-malignant pain with opioids, as well as identify those persons who were abusers of prescription, opioid drugs.5-8 Both situations correctly appeared to be public health and clinical needs which have progressively emerged and been addressed until this time. Initially, a small cohort of non-malignant pain patients in Los Angeles County were admitted to out-patient, opioid therapy.2,8 Some of the initial cohort are still alive and in treatment. Thirty (30) chronic, non-malignant pain patients treated with opioids for at least 10 years are reported here. Ten (10) of these patients have been treated for over 20 years and are individually tabulated to provide physicians and other interested parties with specific information on some of the few long-term patients who are available for study.
Almost all patients report that their pain has permanently decreased over time, and the majority believe that opioids continue to relieve their pain now as well as when their treatment was initiated. All patients report they can now do a variety of activities and physical functions that they could not do prior to opioid therapy. This follow-up shows that long-term, daily opioid therapy can be associated with positive clinical outcomes.
Criteria for Admission to Opioid Treatment
Patients were treated at an ambulatory clinic in Los Angeles (West Covina) County, California, USA. All were referred by physicians who had declared the patient to be intractable and had initiated a variety of pain treatments that were incompletely controlling the patient’s pain. Documentation of chronic pain severe enough to require daily, around-the-clock dosing with opioids was done by medical and pain history, review of past medical records, physical exam showing some evidence of sympathetic discharge (i.e. tachycardia, mydriasis, hypertension) and family member validation that pain was disabling and interfering with activities of daily living. To be eligible for opioids, patients had to experience their pain as “constant” and report that it impaired some physiologic functions such as sleep, eating, concentration, memory, and endurance.
Clinical Treatment Procedures
The initial choice of opioid medication was based on previous exposure or experience and the options offered by the patient’s health insurance plan. Initially, patients attended the clinic weekly to confirm stabilization following opioid induction and titration. After this period, follow-up visits were monthly. Long-acting opioid dosages were titrated upward over a four to six week period to reduce baseline pain and suppress sympathetic discharge signs. Short-acting opioids were added to the regimen to provide rescue medication for pain flares or breakthrough pain. All patients were taught stretching and weight-bearing exercises specific to their pathology. Patients were highly encouraged to take daily vitamins and other dietary supplements and to eat a protein-rich diet to provide an abundant supply of systemic amino acids. Periodic opioid urine and blood tests have been done to verify compliance and help eliminate any non-prescribed, abusable drugs.
In June and July of 2008, the 30 patients reported here were evaluated by chart review and a 19-point questionnaire completed by the patient.
Specific questions were asked to provide basic knowledge related to the treatment outcomes of these individuals:
- Has pain increased, decreased, or remained static?
- What activities can now be done that couldn’t be done before beginning opioid treatment?
- What complications from opioids or the pain have developed during treatment?
- Do opioids still provide pain relief or have they lost potency?
- What exercise and dietary measures do you do? Charts were reviewed for details including opioid dosage, serum levels, and medical complications or consequences.
Characteristics of Patients
This group of patients consists of 18 females and 12 males. Ages range from 30 to 79 years. Major causes of their pain are post-trauma neuropathies and arthropathies, spine degeneration, and abdominal adhesions or neuropathies (see Table 1). The opioids taken are quite varied, but almost all patients take a long-acting opioid formulation of morphine, oxycodone, fentanyl, or methadone. Most use one or more short-acting opioids for breakthrough pain or emergency pain flares (see Table 2). All take a variety of ancillary medications such as muscle relaxants, sleep aids, hormone replacements, and dietary supplements. The majority (27; 96.7%) report they do regular stretching exercises. Most eat a breakfast (20; 66.7%) and have a protein-rich diet. (25; 83.3%). All take one or more vitamins or other dietary supplements (see Table 3).