Opioid Therapy Clinical Guidelines
According to the American Pain Society and American Academy of Pain Medicine clinical guidelines for the use of chronic opioid therapy in chronic non-cancer pain, there is no evidence to support the belief that long-acting opioid (LAO) treatment is superior to short-acting opioid (SAO) treatment with regard to either safety or efficacy.1
The guideline states that for initial therapy, SAOs may be preferred to LAOs because of their shorter half-lives and reduced risk for overdose. It further recommends that “opioid selection, initial dosing, and titration should be individualized according to the patient’s health status, previous exposure to opioids, attainment of therapeutic goals, and predicted or observed harms.”
When it comes to long-term therapy, however, a number of experts often recommend the use of LAO over SAO opioids.2 It has always been assumed that LAOs: provide more consistent and stable serum levels, and therefore more stable analgesia and enhance compliance secondary to reduced frequency of dosing. The initial use of SAOs to establish baseline requirements followed by a transition to LAOs is often urged.3-6
Start Low, Go Slow
Patients should be started on an SAO opioid, titrated to efficacy, and then switched to an LAO. This prevents significant opioid-related adverse effects, like nausea, vomiting, sedation, and respiratory depression.
People develop tolerance to these side effects, meaning that with continued use, the same dose will result in less nausea and sedation. Individual patients differ significantly in their sensitivity to these side effects. Therefore, the safest approach is to start with a low dose, even if it’s unlikely that such a dose will provide adequate analgesia, and increase the dose according to the patient’s response. If there is significant nausea or sedation, then the dose is increased more slowly.
Because sustained-release (SR) formulations are designed for continued drug release over a relatively long time period, it is not in the best interest of an opioid-naive patient to begin with a SR formulation that may result in nausea and/or sedation for many hours.
It is appropriate to use SAOs during the first 2 weeks of therapy because it is a good idea to initiate chronic opioid use with a SAO. But once an effective dose has been reached, it makes sense to transition the patient to an equivalent SR formulation.