Risks Of Chronic Opioid Therapy

Risk of Opioid Addiction

Some primary care practitioners are more comfortable prescribing a medication such as tramadol hydrochloride (Ultram) because it is not a pure opioid agonist. Ultram, a synthetic mu agonist drug combined with a selective serotonin reuptake inhibitor (SSRI), was found to provide more effective pain relief than placebo in patients with chronic LBP (Chou & Huffman, 2007a).

Practitioners who are considering prescribing long-term opioids for LBP should be aware of recent research findings related to levels of addiction. Although many practitioners fear that patients who take long-term opioids will develop addiction, the actual facts support a different view. A 38-study systematic review of opioid use for treating LBP revealed that opioids commonly are prescribed for LBP and that they provide benefit for short-term use. The benefit for long-term use was less clear (Martell, O'Connor, Kerns, Becker, Morales, et al., 2007). Additional findings from this analysis indicate a high incidence of substance abuse disorder and a 24% occurrence of aberrant medication disorder (Martell, O'Connor, Kerns, Becker, Morales, et al., 2007).

Determining the true incidence of addiction in primary care patients who take long-term opioids is difficult, and more data are needed to make a definitive finding. However, there are some studies that address this question. In one study of 800 patients seen in primary care practices for chronic pain and taking opioids, the rate of addiction was roughly 4% (Flemming, Balousek, Klessig, Mundt, & Brown, 2007). In another study, the incidence of addiction in primary care patients was found to be 0.97% in opioid naive patients and 4.37% in those patients who had used opioids previously (D'Arcy, 2009b; Fishbain, Cole, Lewis, Rosomoff, & Rosomoff, 2008).

The low rate of addiction in these studies should reassure prescribers that, although there is a risk that addiction could occur, the majority of patients are able to take opioid medications long term without becoming addicted.

Clinical Pearl

Opioid-Induced Hyperalgesia Syndrome

Opioid-induced hyperalgesia is another very real risk of COT. When this syndrome develops, patients often will say they "hurt all over," and even normal touch can cause extreme pain. The pain intensity is considered to be much higher than the pain stimulus would indicate and is thought to be unrelated to the original pain stimulus (DuPen, Shen, & Ersek, 2007). This syndrome is considered to be an atypical hyperalgesic state caused by long-term use of opioids that create pain generation in the central nervous system and no longer require nociceptive input to create the pain sensation (DuPen, Shen, & Ersek, 2007).

With all the considerations and limitations surrounding the use of opioids for chronic LBP, there still will be patients for whom this is the only option. For these patients, the prescriber should be aware of the guidelines that provide information and guidance on practice recommendations for long-term opioid use. For those patients who are having pain that requires opioids, the positive results that the use of these medications can provide, such as improved quality of life and increased functionality, should be kept in perspective.

Opioid naive: A patient who has not been taking opioids prior to the start of opioid therapy Opioid tolerant or dependent: A patient who takes opioid medications regularly (every day)

Using opioids in these two groups is very different. Opioid-tolerant patients may require more medication for new pain, such as postsurgery pain. Although opioid-naive patients require more monitoring for adverse effects at the beginning of opioid therapy (D'Arcy, 2010).

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