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All Opioids Articles

Background: 3 Waves of the US Opioid Crisis The United States remains in the depths of an unprecedented epidemic of opioid-associated morbidity, mortality, and misuse.1 Opioids (both prescribed and illicit) accounted for more than 70% of deaths from drug overdoses in 2019, highlighting the persistent nature of the public health crisis.1 The CDC has since categori
On July 16, 2021, the Board of Scientific Counselors (BSC)of the CDC National Center for Injury Prevention and Control (NCIPC) held a public meeting by podcast. The agenda for this meeting was three-fold:
A high Fear Avoidance Behavior Score may be a stronger indicator of a patient’s inability to cease chronic opioid analgesic therapy (COAT), according to findings from a recent study.1 The program, led by Marcelina Jasmine Silva, DO, focused on patients with chronic non-cancer pain and aimed to cease COAT among 109 patients based in Northern California via a multidisciplinary program
With the deadly COVID-19 pandemic entering its second year and so many novel issues for pain care providers to grapple with as a result, it is perhaps understandable that the urgency of the United States’ opioid overdose epidemic slipped a bit on our collective radar.
The fentanyl transdermal patch is a unique formulation that utilizes a transdermal system for providing sustained action with a short-acting medication such as fentanyl. This mechanism allows for the treatment of pain in opioid-tolerant individuals with stable chronic pain who require long-term analgesic therapy with an opioid.
The Clinical Pharmacogenetics Implementation Consortium (CPIC)* recently published a clinical practice guideline on the use of pharmacogenetic information for opioid therapy for pain control.
Although prescribing of opioids has declined because of safety concerns in recent years, it is important to differentiate true allergies from other intolerances that exist with opioids, namely, adverse events and pseudo-allergies. Two types of opioid-related allergic reactions are: immunoglobulin E-mediated or due to mast cell degranulation (Image: iStock).
Editor's Note: This commentary is based on a paper recently published by Tvetenstrand and Wolff titled "Reduced opioid use and reduced time in postanesthesia care unit following preoperative administration of sublingual sufentanil in an ambulator surgery setting" in the Journal of Clinical Anesthesia and Pain Management.   
Most practitioners are aware that opioids and benzodiazepines are not recommended to be prescribed concurrently.
Extended-release (ER) opioids are increasingly viewed as an inappropriate treatment for chronic pain. At a community health clinic visit earlier this year, I was told that their physicians are currently discouraged from prescribing ER opioids.
Perspective: The Real Meaning of Opioid-Induced Hyperalgesia Dear PPM,
A case presentation on the use of opioids in those with chronic kidney disease and diabetic peripheral neuropathy.
Inside the potential of glial cell modulators for disease modification and pain management including OUD, opioid tolerance, and hyperalgesia.
Medtronic’s new risk-assessment platform may help to identify vulnerable patients before opioid therapy begins.
The majority of Medicare Part D patients diagnosed with OUD were not identified as overutilizers.
Direct-acting opioids may be a better options for depressed patients on SSRIs.
Tracking the prevention methods of prescription opioid misuse and overdose deaths by 2025.
Benzodiazepines are accounted for a growing number of overdose-related deaths
A compounded formula using codeine could lower patients’ overall opioid doses, according to one doctor's novel research.
Beyond the opioid crisis, new challenges—and hopes—await the pain practice community.
Inside the unique properties of Nektar Therapeutics’ new abuse-deterrent opioid, NKTR-181, and its potential for treating low back pain.
In a close vote, panel members remain divided. More news coming soon.
While opioid prescribing rates decreased over a nine-year period, certain factors led to differences in prescribing.
While use was associated with reduced pain and improved physical functioning, there was an increased incidence of vomiting.
Buvidal is the latest opioid dependence and withdrawal medication currently in the pipeline.
What are the associations of opioid use disorder with outcomes of cardiovascular surgery?
Dr. Mary Lynn McPherson's second edition of her book, focusing on opioid conversion, offers healthcare providers strategies for calculating and prescribing opioid dosages.
Opioid use disorder (OUD) is on the rise among pregnant women: what clinicians can do to help monitor and treat pain in female patients.
Pain practitioners should turn to VA resources when assessing and treating chronic pain in Veterans.
Common characteristics of opioid misusers among college students were found in a new study.
Inside abuse-deterrent formulations – and their potential impact on the opioid epidemic.
Despite evidence of benefitting OUD, MAT treatments are not made available to the vast majority of patients.
What do patients really think about opioid vs non-opioid medications for chronic pain?
Alternative therapies for MSK pain, osteoarthritis, post-herpetic neuralgia, and peripheral neuropathy.
Chronic pain remains the same or gets better after stopping opioid treatment, according to a new study.
Medications which are commonly prescribed to people with dementia have been linked to an increase in harmful side-effects.
Agency continues its efforts to broaden access to generic versions of opioids formulated to deter abuse.
FDA will complete its review of REMOXY ER in August 2018.
This article provides a sneak preview into the upcoming July/August 2018 issue of Practical Pain Management.
The agency said it will continue to evaluate the use of market drugs and take regulatory action where needed.
With opioid misuse and abuse on the rise, other opioid receptors may be targeted for pain relief.
Knowing a patient has consumed their prescribed medication may prevent improper diversion of pills and overdose.
If approved by FDA, IV tramadol would be the first Schedule IV intravenous opioid in the US.
AcelRx is planning on resubmitting an NDA for DSUVIA to FDA in Q2 2018.
Elevated use of gabapentinoid misuse and abuse may be a problem with monitoring opioids.
With appropriate treatment and follow-up, individuals can reach sustained long-term remission from OUD.
New lead into understanding the pathophysiology of opioid physical dependence
The use of cigarettes to alleviate chronic pain may be increasing patients' symptoms and putting them at higher risk of opioid misuse. and upping their risk of opioid misuse.
UN calls untreated pain cruel and inhumane, yet in the US chronic pain patients are losing access to needed opioid therapy to manage severe, intractable pain conditions.
Readers raise questions about the one-sided view of the so-called opioid-epidemic, hormone therapy, and long-term opioid care.
Expert give you advice on how to switch from Opanan ER to another long-acting opioid.
An argument in support of providing patients with an opioid prescription for dosages over 90 MME daily to manage severe chronic pain.
Assessment of abuse-deterrent opioid medications designed to lessen access to active ingredients while maintaining analgesic effects for chronic pain patients with appropriate need.
This month's Editor's Memo focuses on how Medicare and Medicaid are planning on adopting CDC Guidelines for Safe Opioid Prescribing.
A perspective on several common terms that are widely used by pain practitioners but often are misunderstood by professionals, patients, the general public, and the media.
A multitude of pharmacokinetic changes that occur with aging should be considered when pain prescribers consider which medications to prescribe to avoid drug-drug interactions in the elderly.
Pain practitioners are urged to recognize painful genetic disorders, which fall into 3 categories: connective tissue, metabolic, and neurologic, as they require aggressive, palliative pain care for these usually progressive conditions.
In this Guest Editor's Memo, Seddon R. Savage, MD, MS, discusses issues of treating opioid use disorder in patients with chronic pain.
Challenging insurance policies that hinder management of opioid use disorders.
In a patient with chronic pain who develops an opioid use disorder (OUD), what factors go into the decision of whether or not to wean the patient off opioids? Jordan L. Newmark, MD
Readers are better informed about use of the PPM Opioid Calculator and the benefits of metformin.
Given the recent focus on the opioid abuse epidemic, Practical Pain Management asked the authors to review what efforts the FDA has taken to help combat abuse of these medications.
Dr. Forest Tennant, MD, explores the impact that the CDC opioid-prescribing guidelines have had on chronic pain patients.
Call the forgotten opioid, physicians are rediscovering levorphanol as a safe and effective pain medication.
Learn how emergency room physicians, dentists, rheumatologists, and orthopedic surgeons are dealing with new regulations and guidelines for pain management.
There are no perfect medications. This applies to both nonsteroidal anti-inflammatory drugs (NSAIDs) and opioids. A high level of mortality is associated with both NSAIDs and opioids.
We wish to address 3 underappreciated, but salient points regarding tapentadol therapy using a case-based approach: First, the rarity of a true opioid allergy; second, the chemical similarity of phenylpropylamine opioids (tramadol, tapentadol); and, third, the unique pharmacodynamic attributes of tapentadol in the treatment of complex regional pain syndrom
Genetic testing for metabolic abnormalities are critical tools for identifying patients who may require high-dose opioids.
Dr. Jennifer Schneider describes her experience with prescribing extended-release OxyContin to chronic pain patients.
A closer look at the debate between the Los Angeles Time reporters and Purdue Pharma regarding OxyContin's 12-hour dosing schedule.
Dr. Forest Tennant shares his views on the new CDC Guidlines on Opioid Prescribing, as well as introduces Don L. Goldenberg, MD, the newest member of the PPM Editorial Board.
Learn more about how the new APS guidelines on postoperative pain management effects chronic pain patients already on opioids.
Doctors are increasingly being charged assessing patients for pain management, including their risk of opioid addiction. Learn more about the signs and treatment for substance use disorders.
Practical Pain Managements experts answer the question: Is tapentadol a glorified tramadol?
Opioid-induced constipation affects many patients. But instead of suffering in silence, patients may benefit from new and emerging therapies directed at the root cause of the constipation.
Question: Should I discharge a patient on Percocet (oxycodone/acetaminophen) for chronic back pain with unexpected oxymorphone detected in her urine drug screen?
What do you do when a patient can not absorb oral pain medications? Read Dr. Forest Tennant's Editor's Memo to find out.
Learn more about the myriad of agents that can be used to reduce the symptoms of opioid withdrawal.
What does the pain community do with patients who have been taking high-dose opioids for years? Read Dr. Forest Tennant's Editor's Memo to find out.
Many pain patients are being forced to reduce or limit their use of prescribed opioid medications. Dr. Forest Tenant discusses the sad state of affairs surrounding opioid prescribing.
Table turn on pain psychologist who undergoes rotator cuff surgery. Steven D. Passik, PhD, experiences first-hand how pain management and assessment is handled in a busy orthopedic practice.
Dr. Lynn Webster sits down with PPM to discuss abuse-deterrent formulations for reducing abuse of opioids.
Guidelines for opioid prescribing suggest starting low, and going slow--usually with a short-acting opioids and then transitioning to long-acting opioid.
After a steep climb between 2002-2010, abuse of prescription opioids appears to be on the decline--in part due to improved regulations and new formulations of opioids.
Methadone is an inexpensive, long-acting opioid that may be particularly beneficial in patients with neuropathic pain or opioid-induced hyperalgesia. However, methadone is challenging to use. This guide describes Methadone’s unique characteristics.
Many states are now requiring that physicians justify or provide a rationale for daily opioid dosages above a specified amount. The “trigger” dosage usually ranges from 80 to 120 mg. The authors present a rationale for treating moderate to severe chronic pain with opioids.
For patient with rheumatoid arthritis who are currently taking a disease-modifying antirheumatic drugs (DMARDs), the use of opioids may be beneficial for those with chronic pain. However, there are no long-term studies with definitive results to support their concurrent use. Patients and clinicians also should be aware of the risk related to use of DMARDs and opioids, and therapy should be regularly reviewed for efficacy and safety.
Studies in the United States suggested that the prevalence of opioid-induced constipation (OIC) in patients with non-cancer pain ranged between 40% and 50%. Patients do not develop a tolerance to this side effect of opioids. This article reviews new and emerging therapies that target the cause of OIC.
The November/December Editor's Memo by Forest Tennant, MD, DrPH, reviews two recent reports on the status of pain management today. His conclusion: Provide care with caution.
The discovery of dysfunction of endogenous morphine, which leads to the development of many chronic pain conditions, may lead to promising new safe and effective treatments.
Almost half of all diaylsis patients suffer from chronic pain. However, there are virtually no recommendations for pain management in the dialysis setting.
A patient asked to be taken off her opioid because her family thinks she has become addicted. Dr. Jennifer Schneider walks through the difference between opioid dependence and opioid addiction in this Ask the Expert column.
Fatal drug interactions between opioids and benzodiazepines, alcohol, and other sedative-hypnotic drugs have been well publicized and studied. Less publicized, however, are serious and potentially fatal drug interaction between pain medications and illicit drugs, including the ever-growing number of novel street drugs.
Recently, healthcare professionals and the general public have been deluged with information about deaths from opioid (and other drug) overdoses, about patients who misuse or divert their prescribed opioids, about doctors who are, in fact, criminals who run pill mills, etc.
  History A 24-year-old African American female with a history of sickle cell disease was admitted to the hospital for severe pain in her arms and legs bilaterally, which was typical of her previous episodes of sickle cell crisis. Since the age of 12, the patient has had more than 20 sickle cell attacks a year.
From what I can ascertain, therapeutic tolerance is the most misunderstood aspect of the medical management of pain. What’s worse, everyone including physicians and non-physicians either seems to think they’re an expert on tolerance or feel tolerance is irrelevant.
Question: Does adding naloxone to buprenorphine offer any benefit over using buprenorphine alone for the treatment of chronic pain?
It is not uncommon for patients to present to their first pain clinic appointment with the expectation that they will receive opioid medications to treat their non-
Much has been written about the controversy surrounding the release of Zohydro (hydrocodone), which won Food and Drug Administration approval despite a 12 to 2 vote against the agent by the advisory committee. Many experts in pain management and drug psychiatry are concerned that the new drug will become another focal point in the country’s epidemic of opioid abuse.
Question: Is there a benefit to using long-acting versus short-acting opioids for chronic pain?
Drug testing commonly is used in clinical, criminal, and workplace settings.
As I travel around the country, two issues keep surfacing: 1) the abrupt cutting off of legitimate patients from opioids, producing withdrawal and re-emergence of their pain; and 2) the bias against the use of opioids by states, even for legitimate pain patients. 
Question: A patient recently found out that she has a genetic mutation, cytochrome P 450 (CYP450) 2D6, and that she is a poor metabolizer. One of her alleles is null, while the other works at a very low rate. I am not that familiar with these mutations, and I am hoping you may be able to give me some more information on what the mutation is?
Prescription opioid misuse, abuse, addiction, overdose, and diversion have become crises on local and national levels.1-6 The latest statistics from Drug Abuse Warning Network (DAWN) estimates that over 1.2 million emergency department visits in 2011 involved nonmedical use of prescription medicines, over-the-counter drugs, or other types of pharmaceuticals.
Pain is one of the most common reasons patients visit a health care professional. Professionals spend a great deal of time learning how to diagnose and treat pain-related medical problems but much less time learning how to document the process.
Question: I have recently read a lot on Twitter that NSAIDs cause more deaths than opioids. Can you clarify if that is true?  
Question: Should you test for and treat opioid-induced hypogonadism?
Osteoporosis is being recognized more frequently as a side effect of long-term opioid therapy. Screening should be considered in all patients on chronic opioid medication because treatment is much more effective when osteoporosis is detected early.
FDA rules on extended-release and long-acting opioids. Read PROP and PROMPT responses, as well as PPM Editorial Board comments.
The US Food and Drug Administration (FDA) announced labeling changes for all extended-release and long-acting (ER/LA) opioids.
After over a year of debate, petitions, and hearings, in September of 2013, the FDA announced class-wide safety labeling changes and new post-market study requirements for all extended-release and long-acting (ER/LA) opioid analgesics intended to treat pain. PPM asked the authors of PROP and PROMPT, as well as our Editorial Board, to weight in on the ruling.
Buprenorphine has a unique pharmacological profile, and while much remains to be learned, it is clear that it is an important treatment option for the management of moderate to severe cancer and non-cancer pain syndromes
This article will review the substantial differences among the available opioid conversion calculators.
UDT should be something you do “for our patients.” Ordering the “right test” for the “wrong purpose” can result in completely erroneous information being presented and applied to the clinical care of the patient.
A 38-year-old man who weighs 280 lbs owns his own business and takes 300 to 450 mg of oxycodone 30-mg tablets each day. He attends the pain clinic with his wife who is a licensed registered nurse. He and his wife state that with opioids he works full time. The problem is that recent urine screens show no oxycodone. Both patient and wife claim he faithfully takes his oxycodone as prescribed. What should the physician do?
Not all patients respond the same to any given opioid. This fact is well known to pain practitioners. In this journal, we have previously discussed some of the reasons why this occurs—genetic polymorphism, pharmacokinetics, and pharmacodynamics. But one less obvious reason may be opioid malabsorption.
Testosterone Deficiency Do you know what would be the incidence of testosterone deficiency in a 57-year-old male on chronic opioid use (OxyContin)? —Carlos Omar Viesca, MD
Since the FDA changed hydrocodone combination products from a schedule III controlled substance to a schedule II, pain practitioners and their patients need to know their options.
Readers write in about identifying trigger points in migraine patients, treating TMD as an orthopedic problem, and how you taper high-dose opioid patients.
Managing high-dose opioid pain patients can be challenging for pain physicians. Our board members recommend a strong push for collaboration and education.
Our experts explore effective carbamazepine concentrations in trigeminal neuralgia patients and review opioid efficacy evidence in moderate-to-severe pain.
The author explores the need for ultra-high dose opioid use in chronic pain patients, and outlines personal procedures to ensure safety and efficacy.
Can Sustained-release Morphine Tablets Be Administered Rectally?
The Editor in Chief of Practical Pain Management gives practical guidelines for understanding CYP enzyme test results.
PPM sat down with Steven D. Passik, PhD, a leading pain and addiction expert, to discuss how clinicians can better equip their practices to properly identify pain patients best suited for opioid therapy.
YALE, 1981— I was walking down the hall with William Collins, MD, chairman and Cushing professor of neurosurgery, talking about the Pain Clinic. He told me about a case of a man in his mid-30s suffering from intermittently moderate to severe rectal spasms, which had failed to respond to multiple therapies for more than a decade.
Experts weigh in on best practices for prescribing opioids when there is concern about potential abuse.
Most pain practitioners have a few patients who use up their pain medication more quickly than expected. They often claim their medication is just not enough to cover their level of pain.
Patients and providers should be aware of the abuse potential, the risk for respiratory depression and death, the possibility of drug interactions, the dangers of heat exposure, and the risks associated with accidental exposure to fentanyl patches.
The debate continues about whether opioids are safe and effective for long-term use in the treatment of chronic non-cancer pain. Exclusive report on PROP vs PROMPT from October 2012 in PPM.
In an effort to curb the abuse and misuse of long-acting/extended-release opioid analgesics, the FDA created a voluntary risk evaluation and mitigation strategy (REMS), which requires prescriber education and patient counseling.
Members of Practical Pain Management's Editorial Board weigh in on the PROP petition.
In Ask the Expert, Dr. Jennifer Schneider argues that methadone is an excellent drug for treating chronic pain--but that it is not a long-acting analgesic.
Article provides 3 simple assessments pain practitioners can adopt or modify for use in their own long-term outcome evaluations.
PPM asked Andrew Kolodny, MD, president of PROP, to answer questions that have been raised about requested opioid label changes.
A new model for methadone conversions aims to better mirror the continuity that prescribing physicians may expect to occur over a range of dosing conversions.
Educational review highlights potential drug-drug interactions for clinicians so they can develop strategies to avoid or ameliorate them.
Article recommends genetic testing for cytochrome P450 deficiencies in patients who require high-dose opioid therapy.
Currently, morphine is used medicinally worldwide in acute and chronic pain management. Article details 4 commonly recognized sources of morphine.
A patient using neuropathic agents and opioids lives alone, and her doctor notes increasing dementia. What is your ethical responsibility for making sure she's safely taking her medications? A pain expert addresses this opioid-related question.
PPM Editor in Chief Forest Tennant discusses the semantic debate surrounding the terms "narcotics" and "opioids."
What's the proper way to dispose of prescription medications, especially opioids? Learn what you should be telling your patients.
How should you recommend your patients dispose of opioids? Tips from pain experts.
Opioid can cause opioid-induced constipation. This review is the first part of a series of articles that will focus on opioid-induced complications.Focuses on bowel dysfunction (OIBD), and more specifically opioid-induced constipation (OIC).
Visit the PPM Opioid Calculator.   PPM: What are the challenges facing physicians when prescribing [dosing] opioids, or switching from one opioid to another?
Practical Pain Management recently surveyed our Editorial Board members and asked them what safety measures they’d recommend when prescribing methadone. Read their answers here, and they may help you in your pain practice.
Practical Pain Management wanted to address the major safety concerns for prescribing physicians and patients regarding methadone use in pain management. To explore this topic, we spoke to Lynn R. Webster, MD, FACPM, FASAM, and Mary Lynn McPherson, PharmD.
In-depth article on the use of methadone in chronic pain management.
Editor's Memo from the March 2012 issue of Practical Pain Management. The issue focuses on the use of methadone in treating chronic pain, and the Memo focuses on if ECG screening should be done before initiating methadone.
How do you prevent an accidental overdose of opioids in chronic pain patients? The Practical Pain Management Editorial Board provides useful opioid management tips.
How do you manage a patient who self-escalates his or her opioid use? Two pain experts answer this opioid management question.
Tips on prescribing opioids to chronic pain patients: a pain management specialist tells pain practitioners which three opioids to never prescribe in combination.
Prescription drugs are newsworthy, particularly when they are abused in violation of their intended medical purpose. Conservative radio commentator Rush Limbaugh grabbed many headlines when he admitted his own misuse of the painkilling opium derivatives known as opioids.
Ask the Expert question on opioid tolerance in chronic pain patients: what should you know?
What do you do when a patient can't make it to an appointment, but he or she needs an opioid prescription renewed? This Ask the Expert features answers from a lawyer and a pain management specialist.
This article describes my definition of central pain, the method and results from my study, and the conclusions I have drawn from the results. Although I recognize that the study is small and relies on patients’ self-reports, I do believe that the results provide an interesting insight into the fundamental question of which treatments patients with central pain find helpful.
A pain physician is worried about the risk of overdose or sedation caused by opioids. In this Ask the Expert article, a pain management specialist responds to those opioid concerns.
The new indications in the PDR for opioids now carry the highest mandate for prescribing this class of drugs to patients. Learn more about the FDA and PDR indications and warnings for opioids.
Various treatments are available for chronic pain, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), opioid analgesics, and other treatments such as anticonvulsants and antidepressants. This article will discuss opioid analgesics.
Article discusses a previously unreported metabolite of high-dose morphine treatment—hydromorphone—for chronic pain patients.
Article describes opioids for chronic pain management. Learn about office-based treatment for opioid dependence.
Article discusses oxycodone to morphine rotation. Provides one opioid rotational procedure found to be effective in chronic pain patients.
Chronic pain is a significant problem in the U.S. today. 35% of patients have chronic pain. Over 50 million Americans are partially or totally disabled by chronic pain. Over the age of 50, one out of two people suffer from chronic pain. Under-treatment of chronic pain runs as high as 50%.
Random urine drug testing—applied fairly and without prejudice—can mitigate the stigma associated with drug monitoring of patients taking controlled substances.
The criteria for optimal opioid dosing for a specific patient must be clinically adequate pain control and functional improvement while avoiding cognitive impairment and respiratory depression.
The one drug class that has the optimum profile to manage severe, unremitting, intractable pain—opioids—is often shunned due to social stigma, lack of dosing guidelines, misunderstanding of side effects (addiction, respiratory depression), and a pervasive fear of unwarranted regulatory persecution.
Urinary drug testing as a means to assure compliance and monitoring of proper medication use is becoming common place in the clinical practice of pain management.
Determination of opioid levels in the blood is emerging as an important tool for ensuring the safety, effectiveness, and integrity of opioid analgesic therapy in the treatment of chronic pain.
As more opioids are prescribed, doctors need to be increasingly vigilant about documentation. Article outlines how aggressive DEA action against drug abuse and diversion ensnares some legitimate prescribers.
Despite fears fueled by negative press, opioid therapy—with proper evaluation and safeguards—is a legitimate, viable, and essential tool in managing severe, intractable, non-cancer pain.
Prescribing opioids for chronic pain requires set rules, a written plan, periodic re-evaluation, and vigilance to prevent illegal diversion of controlled substances. Learn about opioid abuse and diversion.
Selected chronic pain patients, treated with opioids in a structured program, can improve function and maintain employment.
Characterization and profiling of patients with deviant addictive behaviors helps weed out abusers from pain practices.
For patients experiencing side effects from opioids, switching the delivery and type of pharmaceutical can often provide pain relief.
History: A 37-year-old white male was referred for pain treatment by a physician in a local methadone clinic. The patient’s pain started 3 years earlier when he suffered an industrial injury while pulling a heavy, electric cable.
A pair of investigations recently published in the Archives of Internal Medicine report that elderly patients with chronic noncancer pain taking opioid analgesics have higher risks of serious adverse events (AEs) than those taking NSAIDs; plus, the opioids varied among themselves in AE potential.1,2 These studies appear to contradict current guidelines and caution against
There continues to be great interest in the study of genetic defects of chronic pain patients who have difficulty metabolizing opioids. This is especially true as more and more pain patients are requiring high opioid dosages and/or an unusual regimen.1,2
It’s a puzzling situation. History and science are pretty clear: the simultaneous use of stimulants and opioids have, for over a century, been reported to be a superior combination for pain relief. 1 So, based on history, why isn’t every patient who’s taking opioids also taking a stimulant?
Naloxone is a well-tested antidote for reversing often-fatal respiratory depression due to opioid overdose poisoning. So, the prescription of naloxone for at-home intranasal administration, along with complete instructions for its emergency use, may be the best antidote for stemming rising rates of prescription-opioid overdoses and fatalities in the United States population.
John (not his real name) is a 51-year-old chronic pain patient that I have been seeing since 2003. His pains began in 1981 with a motor vehicle accident. In1985 he broke an ankle and in 2000 he developed chronic inflammatory demyelinating poly-neuropathy. John had another motor vehicle accident in 2002, developed diabetes and, in 2008, added a diagnosis of Stage IV lung cancer.
Opioid medications are a reasonable treatment option for carefully selected patients who suffer from psychiatric endogenous opioid dysfunction syndrome and who have not responded to typical neuropsychiatric medications or other treatments.
Article explains chronic pain syndrome and discusses why some patients require high dose opioid therapy.
Implementation of multiple risk assessment and monitoring strategies appears to lower the rate of inappropriate urine drug testing results in a clinical setting.
Guidelines for the likely 20 to 30% of pain patients who have a genetic defect involving one of three major CYP450 enzymes and so cannot effectively metabolize certain opioids that must be converted to a metabolite to be effective.
Compliance monitoring using laboratory screening and confirmation, together with physician education, can support an effective risk mitigation strategy. Important article for pain physicians prescribing opioids.
Pain patients who do not respond to the analgesic properties of opioids have a chance of being genetically incapable of generating the clinically active metabolite of these medications. Get tips on when to suspect a patient has CYP-2D6 deficiency.
Opioids applied in a topical cream that directly target the peripheral opioid receptors (which grow in inflammatory pain sites to attract natural endorphin compounds for pain relief and immune enhancement) may have advantages relative to oral opioids.
Patients in this long-term study were found to be functioning quite well after 10 or more years on generally stable opioid dosages, with the vast majority able to care for themselves and even drive. Read what chronic pain patients taking opioids say about themselves.
Thoughts on tolerance, hyperalgesia, and short-acting opioids.
Article highlights an interim report on the opioid treatment longevity study for chronic pain patients.
Available evidence suggests that the opioid antagonists naloxone and naltrexone offer potential benefits for enhancing opioid analgesia as well as monotherapy for managing certain challenging pain conditions.
Laboratory testing for patients receiving prescription opioid pain relievers has been recommended by several organizations and governmental agencies to assure patient compliance, safe use to minimize risk, and assist in the identification of possible drug diversion or misuse of the drug.
There are multiple variables outside of laboratory testing to consider when interpreting a patient's test results and deciding whether or not they are compliant with their medication.
Concurrent therapeutic electromagnetic applications complement opioid treatment and promote enhanced pain control in chronic pain patients.
The goal of ultra-high opioid dosage therapy is to relieve pain and improve function in those chronic pain patients that are profoundly ill, impaired, and/or bed- or house-bound. However, ultra-high opioid dosage should not sedate them. Read which patients require ultra-high opioid dosage.
Strategies for prescribing physicians to identify chronic pain patients at high risk for inappropriate utilization of prescription opioid analgesics.
Urine drug testing is one way to check for compliance in your patients on opioids. Article reviews study that looked at utility of urine drug testing.
Article provides an overview of the role of SR opioids in treating chronic pain as well as how to maintain a chronic pain patient on opioids.
While opioids have been a mainstay in the treatment of acute pain, the role of opioids in treating chronic pain is less well defined and overshadowed by persistent concerns of misuse, abuse, and addiction. Fortunately, during the past 20 years, there have been major advances in clarifying these issues.
The use of opioids in geriatric patients and those with hepatic or renal insufficiency can present significant challenges for clinicians.
Risks associated with opioids can be safely and effectively managed while providing life-saving analgesia to chronic pain patients.
A cohort study explores the role of conditioning factors, dosage stability, opioid agreement violations, patient satisfaction, and the patient's own estimated improve-ment in overall quality of life.
How to interpret and use eye signs to help prescribe opioids for intractable pain.
A 10- and 20-year follow-up of severe, chronic pain patients treated with daily opioids indicates that some chronic pain patients greatly benefit from long-term opioid therapy.
A pain management specialist responds to questions about using opioids in chronic pain treatment. Also discusses multidisciplinary pain clinics and their role in treatment.
Causes, diagnosis, and treatment of a common but an often undiagnosed problem in chronic opioid pain patients, opioid-induced sexual dysfunction.
Article describes a pain professional's viewpoint on methadone successes and cautions.
With its wide margin of safety, low cost, and multiple routes of administration, naloxone is an ideal antidote for opioid toxicity but it should only be used to reverse respiratory depression while closely monitoring the patient.
Structuring opioid therapy for chronic pain patients as well as how patient stratification for certain characteristics can minimize the risk of sleep apnea and respiratory depression are discussed.
Interpreting urine drug tests in pain patients treated with oxycodone requires an understanding that oxymorphone, although considered a minor metabolite, can sometimes equal or exceed urine concentrations of oxycodone.
This article discusses the guidelines for how to wean patients off intrathecal opioid therapy, including why patients should undergo a risk assessment before beginning the weaning process.
While most pain patients are initially treated with short-acting opioids, severe unremitting pain involving biological manifestations requires transitioning to long-acting opioids. Pain management specialist discusses this opioid transition.
Despite the availability of mono-graphs, papers, lectures, and web sites to teach about o
When lifestyle changes and non-pharmacological treatments fail, adjuvant drug therapies
The Unwarranted Attacks on Doctors, Pharmaceutical Companies, and Opioids Must Stop
Article gives viewpoint on the lawsuit that involved the pharmaceutical company that manufactures OxyContin.
Methadone Deaths and Warnings
Routine urine testing is more readily accepted by patients when it is implemented as an integral part of a drug therapy program.
Using Methadone Effectively and Safely as Analgesic
An historical and contemporary view of societal, medical, manufacturer, payer, and legal interactions affecting the prescription and use of opioids for pain management.
A review of the pathophysiology of opioid-related gastrointestinal effects together with treatment options.
Guidelines for Opioid Management of Pain
Practical Pain Management's editor takes on this question: what causes opioid malabsorption? And what can you do about it for your chronic pain patients?
Opioid blood levels in high dose, chronic pain patients.
Collaborative blood level survey of effective opioid administration in opioid-tolerant chronic pain patients.
Collaborative blood level survey of effective opioid administration in opioid-tolerant chronic pain patients.
A comparison of intractable pain patients’ characteristics to those found in drug addicts shows how to discern the difference-both to give the IP patient due care and minimize drug abuse and diversion.
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