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High Dose Opioids
Posted on May 13, 2013 | Tags: Daily Pain Tips, Chronic Pain

Up until now, researchers have only been able to wonder what the effect of using high-dose opioids on patients is. But according to new research, half of patients on high-dose, long-term opioid therapy had hormonal disturbances or signs of inflammation, while 100 percent reported improved pain control and mental outlook. At The Pain Center of Arizona, our pain management specialists realize that opioids and pain medication can have a place in the treatment of chronic pain, however, our pain doctors also respect that there are serious side effects.

The results, reported at the 29th Annual Meeting of the American Academy of Pain Medicine, present rare data on the effects of opioids beyond 10 years. Most clinical trials that examine opioid use are of short duration, and little is known about long-term outcomes, particularly in patients who suffer from noncancer pain.

The 40 patients included in the study were evaluated between July and October 2012. Each had been taking a high dose of opioid therapy, defined as more than 100 mg equivalence of morphine a day, for 10 or more years. Each complained of constant, debilitating pain that was classified as intractable, which is defined in California as "incurable by any known means." They had tried many non-opioid methods to try to control their pain. Every patient in the study also suffered from severe insomnia.

The patients were tested for serum cortisol, pregnenolone, corticotropin (ACTH), testosterone, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP).

All 40 patients reported improvements in depression, hopelessness and quality of life and sustained pain control that accompanied a stable opioid dosage. In addition, all patients reported improvements in at least 1 physiologic function. Categories in which at least 20 patients noted improvements were concentration (27 or 67.5 percent), walking (25 or 62.5 percent), appetite (20 or 50 percent) and movement (31 or 77.5 percent). Seventeen or 62.5 percent of patients reported improvements to sleeping.

Eight patients (20 percent) had hormonal suppression as follows: ACTH in 2 (5 percent), cortisol in 3 (7.5 percent), testosterone in 2 (5 percent) and pregnenolone in 4 (10 percent) of patients. Three patients (7.5 percent) had one or more serum elevations of a hormone as follows: ACTH in 1 (2.of Pain Medicineveractinc5 percent), cortisol in 2 (5 percent) and pregnenolone in 1 (2.5 percent). Nine patients (22.5 percent) had an elevated CRP or ESR.

"The high-dose opioid patients studied here greatly improved many physiologic functions and mental outlook," Forest Tennant, MD, PhD, study author and medical director of Veract Intractable Pain Clinic in West Covina, concluded, writing in a scientific poster. "Despite these improvements, 12 (30 percent) of patients had an elevated serum hormone level, an inflammatory marker, or both, suggesting the presence of an on-going painful, inflammatory process."

Opioid abuse is a very real problem for a lot of patients. So can addiction be prevented?

Short-acting opioids such as Dilaudid (hydromorphone) and Vicodin (hydrocodone/paracetamol) may be helpful for initial pain relief, but longer-term dosing can lead to breakthrough pain and withdrawal, and these agents carry a relatively high abuse potential.

Oxycontin (oxycodone CR) is also widely abused, especially in rural areas; its elevated dosage means it is highly addictable, and coverage by insurance makes it cheaper than heroin.

Longer-acting opioid analgesics such as Suboxone (buprenorphine), methadone, and fentanyl have a much lower abuse liability. However, methadone is found in more overdose deaths than any other prescription opioid and should not be prescribed for opioid-naive patients. Because analgesic effects of methadone are of shorter duration (6 to 9 hours) than its half-life (36 hours), levels may accumulate, leading to respiratory suppression or cardiac events.

Patients should be instructed to keep controlled substances safe in a locked location to prevent use or sale by others.

If a physician intends to prescribe opioids for chronic pain, a narcotic protocol – medication contract, psychological evaluation, and urine toxicology – should be considered. Monitoring both urine toxicology and aberrant behaviors will detect more opioid abuse than either strategy alone.

If you suffer from chronic pain due to any condition or injury, find hope at The Pain Center of Arizona! Our dedicated team of board certified pain management physicians will work with you to treat your pain, increase your functionality and quality of life, and get you back into life! We have locations across Arizona, including Phoenix, Anthem, Surprise, Mesa, Gilbert, Deer Valley, Paradise Valley, Scottsdale, and now Prescott and Tucson! We take multiple insurance plans; click here to see if we take yours! To make an appointment and take the first step toward getting back into life, call us today at 1-888-PAINCENTER. We hope to see you soon!

The advice and information contained in this article is for educational purposes only, and is not intended to replace or counter a physician’s advice or judgment. Please always consult your physician before taking any advice learned here or in any other educational medical material.

©The Pain Center of Arizona, 2013

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