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CMAJ • October 28, 2003; 169 (9)
© 2003 Canadian Medical Association or its licensors

Letters
Correspondance

Opioids and chronic pain

Jacqueline Gardner-Nix

Department of Anaesthesia, University of Toronto, Toronto, Ont.

The WSIB1 and CPSO2 guidelines cited by Jason Busse surveyed data up to 1998; these data involved studies that were conducted over just a few weeks and that did not always assess physical function or report return to work. Lack of evidence, if the studies have not been done, does not mean lack of efficacy. More recent studies have examined quality-of-life issues and have followed subjects for a year or more, and these have demonstrated benefit of opioid medication.3,4,5 Level 2 evidence (strong evidence from at least one properly designed randomized controlled trial of appropriate size) now exists for use of opioids in the treatment of low back and musculoskeletal pain. "Benefit" may be an increased ability to interact with family and friends, better ability to function in the household or improvement in sleep.

In clinical practice, a trial of opioid therapy, with switching of opioids to find one with acceptable efficacy and side effects, may avoid repeat visits from patients with a generally poor response to opioids — such patients can at last be "heard." Once their pain has been addressed, they can move on to other strategies. Anthony Russell and Stephen Aaron cite 2 papers on fibromyalgia, but generally I have found opioids of limited benefit in this condition.

Clinical trials have so far not incorporated opioid rotations6 or opioid blending, strategies that I have used to maintain opioid responsiveness in some of my patients. Of 209 of my current patients with severe noncancer pain who have been offered opioids and followed for 2 to 15 years, 80 (38%) report good pain control and enhanced physical function compared with before their opioid treatment (26/80 [32%] working, 11/80 [14%] retired) and 74 (35%) report minimal improvement in pain control but enhanced physical function (11/74 [15%] working, 15/74 [20%] retired). A further 44 (21%) report minimal improvement in pain control and physical function (none working, 10/44 [23%] retired), but for these patients slow opioid tapering has resulted in greater use of the health care system, as well as greater patient and family distress. The remaining 11 (5%) tapered off opioids because they experienced no benefit.

Jacqueline Gardner-Nix Department of Anaesthesia University of Toronto Toronto, Ont.

References

  1. Chronic Pain Initiative. Report of the Chronic Pain Expert Advisory Panel. [Toronto]: Ontario Workplace Safety and Insurance Board; 2000.
  2. Evidence-based recommendations for medical management of chronic non-malignant pain: reference guide for physicians. Toronto: College of Physicians and Surgeons of Ontario; 2000.
  3. Peloso PM, Bellamy N, Benson W, Thomson GT, Harsanyi Z, Babul N, et al. Double blind randomized placebo control trial of controlled release codeine in the treatment of osteoarthritis of the hip or knee. J Rheumatol 2000;27(3):764-71.[Medline]
  4. Roth SH, Fleischmann RM, Burch FX, Dietz F, Bockow B, Rapoport RJ, et al. Around-the-clock, controlled-release oxycodone therapy for osteoarthritis-related pain: placebo-controlled trial and long-term evaluation. Arch Intern Med 2000; 160(6):853-60.[Abstract/Free Full Text]
  5. Milligan K, Lanteri-Minet M, Borchert K, Helmers H, Donald R, Kress HG, et al. Evaluation of long term efficacy and safety of transdermal fentanyl in the treatment of noncancer pain. J Pain 2001;2(4):197-204.[Medline]
  6. Pasternak GW. The pharmacology of mu analgesics: from patients to genes. Neuroscientist 2001; 7:220-31.[Abstract/Free Full Text]




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