Knowledge Series IV

Treatment of noncancer chronic pain (NCCP) is a challenge. More than 30 million patients suffer chronic pain and an increasing number of primary care physicians are prescribing opioids with associated challenges of side effects, addiction and legal regulations. Clinical practice guidelines (CPGs) are developed using current evidence to assist clinicians in making therapeutic decisions regarding health care for specific clinical conditions.

Treating chronic pain patients is a complex challenge under the best of circumstances, and when the need to proactively assess and treat sleep disorders in these patients is included, patient management becomes significantly more complex. Such patients are excellent candidates for a multidisciplinary approach to pain management, which combines the skills and knowledge of clinicians from diverse specialties to positively impact patient care, and therefore, outcomes.

In many cases, opioids are an effective therapy for the management of moderate-to-severe chronic pain. Although popular belief often exaggerates the relationship between opioids and addiction, the risk does exist. It is necessary, therefore, for the practitioner to be aware of the aberrant behaviors that may be indicative of the disease of addiction or which may play a part in the process of drug diversion. Additionally, the practitioner must recognize that not all aberrant behaviors are caused by addiction, abuse or misuse. In particular, pseudoaddiction may lead to symptoms similar to those of addiction, but these behaviors easily resolve upon obtaining adequate pain management. All patients deserve adequate pain management; the pain practitioner is better able to fulfill this patient right when aberrant behaviors are appropriately addressed.

Opioids can be a successful treatment for chronic, nonmalignant pain, even for long-term use, but are not well tolerated by some patients. Treatment failures occur for various reasons, among them opioid-related adverse events, analgesic tolerance, hyperalgesia, comorbid mental disorders, opioid misuse to seek reward, and addiction. In addition, recent research indicates that individual genetic variations may influence opioid metabolism causing a myriad of inter-individual responses to medications. Assessing a patient's suitability for opioid therapy can increase chances for successful outcomes and alert clinicians to the need to change therapeutic course if opioid therapy becomes ineffective or harmful. Patients should be evaluated for risk of addiction or misuse, the presence of mental disorders, and the type, duration, and severity of pain. The treatment regimen, whether pharmacologic, non-pharmacologic, or both, should be individualized accordingly. Assessment should take place before initiation of opioid therapy and continue as a monitoring activity throughout the course of treatment.

Emerging Solutions in Pain is pleased to offer Knowledge Series IV, a set of four monographs developed to highlight and discuss these important issues in chronic pain management.

Evidence-Based Guidelines for Opioid Therapy
Tabitha A. Washington, MD, MS and Gilbert J. Fanciullo, MD, MS
Release Date: November 14, 2008
Expiration Date: November 14, 2011
Drs. Washington and Fanciullo discuss the development of CPGs, along with the strengths and weaknesses of CPGs for opioid therapy.
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Appropriate Candidates for Opioid Therapy
Lynn R. Webster, MD
Release Date: September 02, 2008
Expiration Date: September 02, 2011
Dr. Lynn Webster discusses the importance of assessing a patient's suitability for opioid therapy to maximize treatment outcomes.
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A Multidisciplinary Approach to the Medical Management of Sleep, Chronic Pain, and Driving
Bradley J. Schnierow, MD, MS and Joseph Shurman, MD
Release Date: May 07, 2008
Expiration Date: May 07, 2011
Drs. Schnierow and Shurman discuss chronic pain and comorbid diseases and syndromes which often induce or exacerbate sleep disorders; and in turn, sleep disorders which may exacerbate chronic pain.
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When Should Opioids Be Discontinued? Assessing Aberrant Medication-Use Behaviors in Patients with Chronic Pain
Penelope P. Ziegler, MD, FASAM
Release Date: April 01, 2008
Expiration Date: April 01, 2011
Dr. Penelope Ziegler, an addiction specialist from Virginia, highlights some of the behaviors that the practitioner may encounter in a pain management practice and describes how they may be effectively managed. Dr. Ziegler discussed the criteria necessary for a diagnosis of addiction, the conditions that should be included in the differential diagnosis and the responsibilities of the practitioner when opioid therapy is discontinued.
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