Individuals who are naïve to opiates or substances of abuse often require minimal opiates due to a lack of tolerance and can be sensitive to overdose. On the other hand, patients who have had previous opiate treatment or have substance abuse problems often require stronger and more frequent therapy. Lastly, patients receiving opiates on an intermittent or chronic basis often require maximum recommended doses. Many communities have pain specialists available to help manage these more challenging patients.
In addition, some patients are poor metabolizers of opiates. For example, it is now understood that poor metabolizers of CYPD26, a key enzyme in codeine and dihydrocodeine metabolism, may not have success in attaining analgesia. Clinical signs, such as tachycardia and hypertension, may indicate that a patient is in acute pain. Likewise, a very long constellation of signs and symptoms, including tachycardia and hypertension, can be seen with opiate withdrawal and central nervous system hyperarousal states. An important clinical pearl is to not automatically assume abuse if a patient reports pain despite receiving medication. Lack of understanding of opioids and concern about governmental retaliation for prescribing opi-oids can result in many clinicians to utilize overly conservative dose adjustments that often lead to treatment failure (Tollison 2002).
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