Opioid Use For Chronic Pain: Help Or Hindrance?

Use of Opioid for Pain Management

Chronic pain lasts longer than normal pain like more than three months. Alternatively it can be defined as pain which have passed the normal time for tissue healing. Chronic pain is the major cause of decreased quality of life and disability. The prescriptions of opioid medications for the management of chronic pain have increased significantly. In comparison to the placebo, opioid therapy was found to be associated with alleviation of short-term pain management. Moreover, the decision making for long-term use of opioid is complex and requires person-centred benefits and risks assessments along with other mitigation strategies, integration of proper risk assessment strategies, mitigation strategies(Chou et al., 2015).

On the other hand, Chou et al. (2015) stated that long-term use of opioid is associated with several negative outcomes and hence non-pharmacological interventions for pain management are getting popular. The following assignment is based on the argument opioid use for chronic pain is help or hindrance. In order to generate an argument about the topic, the assignment will initiative the discussion with importance of using opioid and side-effects of opioid. Next it will throw light on the legislations, policies and procedures using opioid and relevant models of care and ethical principles associated with the use of opioid. At the end, the assignment will highlight non-pharmacological interventions for pain management and its outcomes. This comparative analysis will help to highlight the effectiveness of opioid in pain management.

Use of opioid for pain management

Opioid medications are regarded as the synthetic cousins of opium. The drugs which are derived from opium like heroine and morphine are regarded as the common opioids which are used in the management of the chronic pain management. This chronic pain mainly stems from the traumatic injury like surgery, bone fracture or chronic pain arising from cancer. The main mechanisms of action include the structure of opioid mimics the natural pain-relieving chemical released from the brain like endorphins. Upon mimicking, they reduce the overall pain sensation via modulating the functions of the pain-generating neurotransmitter.

They also muffle the function of the heart rate, respiratory rate and the level of alertness of the brain in order to reduce the sensation of the pain(Nguyen et al., 2013). According to the guidelines of the European Association for Palliative Care (EAPC) step II opioids are commonly used for the initial management of the chronic pain. The systematic review conducted by Caraceniet al. (2012)highlighted that use of codeine and tramadol are effective in controlling pain in comparison to the placebo. Another study highlighted that Tramadol is more effective in the initial management of the chronic pain in comparison to the morphine but is associated with high side-effects. Thus Caraceniet al. (2012)stated that the oral morphine at low dose can be used to provide initial pain relief. However, initiating the pain relief therapy via using step II drug has not been found to provide long-term outcome.

The step III opioid is considered as an important agent for the effective pain management if step II opioid (morphine) is found to be inactive. In Step II opioid, transdermal fentanyl and buprenorphine enables slow increase of the drug concentration in the blood plasma levels. Their long half-lives help in effective management of chronic pain. If the oral opioid, transdermal fentanyl and buprenorphine is found to be inactive in the effective management of pain, oral administration of methadone is considered. Methadone is often used as an alternative for oral morphine. At times in order to give instant relief from pain, opioid switching is followed. Opioid switching is done for substituting one step III opioid with another step III opioid when a satisfactory balance between the adverse effect and the pain relief is not achieved.

Side-effects of Opioid for Long-term Pain Management

Opioid switching has a success rate of 40 to 80% depending upon the physiological mechanism of the individual. The success rate is high when the switch occurs from morphine to hydromorphone or from fentanyl to methadone (Caraceniet al., 2012). Thus it can be said that combination of several opioids can be used to provide relief from the chronic pain. Switching between the opioids further helps to provide effective relief from the chronic pain and this in turn helps to prevent the generation of the opioid tolerance.

Side-effects of opioid for long-term pain management

There are several side effects for long-term use of opioid for the management of chronic pain. First complications include cardiovascular malfunction. Long-term use of opioid for 180 days has been found to increase the risk of developing myocardial infarction. The second complications behind the long-term use of opioid include endocrinological harms (Chou et al., 2015). A cross sectional study conducted by Chou et al. (2015), highlighted that long-term use of opoid cause erectile dysfunction. Erectile dysfunction is associated with increased risk of overall sexual dysfunction. Jamisonet al. (2014)highlighted a completed different perspective behind the increase in the rate of incidence of side effects for opioid use. Jamison et al. (2014) highlighted that many doctors prescribing pain medication have little or no training in the domain of effective main management via the use of opioid.

This increases the risk of medication use. The untrained physicians make inappropriate dosage prescription of medication leading to the generation of adverse health outcome. One of the adverse health outcomes is generation of opioid addiction. Increase in the opioid addiction leads to the development of additional health complications. The study conducted by Manglik et al. (2016) highlighted that the complications or the side-effects of opioid can be avoided via promoting the structure-based discovery of opioid analgesics. Mangliket al. (2016) mainly conducted their study over morphine, an alkaloid from opium poppy which is used to treat pain.

The lethal side-effects of morphine include fatal respiratory depression mediated through the µ-opioid-receptor (µOR) signalling (beta-arrestin pathway). The structural change in the morphine is mainly modulated via the recruitment of the beta-arrestin-2. This leads to the structural modification of morphine leading to its analgesic activation via G-activator proportion. This structural modification of the morphine leads to the decrease in the side-effects of the long-term use of the morphine.

Thus it can be said that the long-term use of the opioid in the management of pain is associate with several side-effects starting from the cardio-vascular complication, respiratory complications and endocrinal complication. Moreover, long-term use of opioid also leads to the generation of habit. This habit generation is further detrimental as sudden cessation of the opioid medication leads to chronic withdrawal symptoms. However, proper regulation of the dosage of the opioid based on age, height weight and requirement can help to reduce the habit forming effect of the opioid. Reduction in the habit forming effect of the opioid further reduces the chances of the development of the additional health complications. At present further research is undertaken in order to reduce the side-effects of the opioid via bringing structural change or the mode of action of the opioid.

Legislations, Policies, and Procedures for Opioid Use

Relevant legislation, policy and procedure

According to the Therapeutic Goods Administration (TGA) by the government of Australia, it is the duty of the physicians to consider few situations while prescribing opioid medications in order to avoid over-dose or addiction. These include real-time prescription monitoring, medication labelling reforms, access of the treatment for the opioid dependence and access to the tamper-resistant medications. Additional factors must be taken into consideration while prescribing opioid medication include improve access of the non-opioid medications for pain management. On May 2015, opioid roundtable was held in Canberra with an aim to improve the patient safety and care towards chronic pain management via opioid. The first consideration of this roundtable is consideration of the pack-size for schedule 8 opioids.

The second consideration includes proper review of the indicators for strong opioids in order to avoid the development of tolerance. The third consideration highlights restriction of the authority of prescribing to specialist doctors. This consideration will help to avoid over prescription of opioid and thereby helping to reduce the consequence of the development of opioid tolerance. The round table conference help at Canberra also provided emphasis on strengthening proper risk management plans for the opioid medications. This risk management program is mainly guided by the Risk Evaluation and Mitigation Strategy (REMS) drafted by Food and Drug Administration (FDA) (Australian Government Department of Health, 2018).

The other regulatory options which must be taken into consideration as highlighted in the round-table conference of the opioid medication management in Canberra include proper review of the label warning over the opioid while framing the dosage or administering the medications and keeping a track of the potential changes in the use of appendices in the poisons standards in order to provide additional regulatory controls for strong opioids.

The Government of Australia – Department of Health (2018) highlighted that increase of awareness among the healthcare professionals are important. This awareness will help to increase their horizon of knowledge in alternative opioids available in the market. This knowledge will further help in the effective management of the chronic pain without the development of opioid tolerance.

The Government of South Australia (2018) has a general principle for the opioid medication list. This general principle highlight that the opioids should be initiated and continued under high caution in order to avoid unnecessary development of opioid dependence and potential diversion of opioids to the “black market”. The general principle also state that before the opioids are used, proper consideration must be given over the non-opioid analgesics and other non-pharmacological approaches of pain management. Government of South Australia also states that while prescribing long-term opioid therapy for the use of the long-acting opioids, proper clinical notes are required to be maintained and consent to the opioid therapy must be taken from the patients. This consent of the opioid therapy will lay a detailed structured of the projected outcome of the opioid therapy and the possible range of side-effects.

Relevant models of care and ethical principles

According to the South Australian Government (2018), the use of opioid for the pain management is appropriate when the pain is short-term and acute while the pathology underlying the opioid is clear. Other principles underlying opioid medication include use of opioid only during chronic pain malignant pain. During non-malignant chronic pain, relevant specialist assistance must be taken. In order to avoid the opioid dependence proper Drug of Dependence Unit must be considered.

Models of Care and Ethical Considerations Associated with Opioid Use

The main ethical regulations that must be taken into consideration while prescribing opioid include deontological approach. Deontological approach promotes justice and “minimize-suffering”. However, it is the duty of the physicians to follow Hippocractic value while prescribing opioid. Under this Hippocractic value, a physician is requested to deny inappropriate use of the opioid for pain management upon the request of the patient(Cohen & Jangro, 2015). This is again supported by the ethical principle of non-maleficence which signifies do not harm. Since over-use of opioid initiates the development of side-effects, the concept of non-maleficence comes into action. Thus opioid medication should only be use when the pain is chronic and demands proper analgesic interventions.

The six step ethical decision making framework for the pain management via using opioid mainly highlight the use of proper pain narrative followed by attempting identifying the pain pathology and pain generators. The third set includes practice of the patient specific practice followed by proper goal settings. The fourth step includes reassessment of the patient progress upon application of opioid. The fifth and sixth step includes interactive clinical ethical analysis and proper pain diagnosis(Cohen & Jangro, 2015).

Non-pharmacological interventions for chronic pain management

Non-pharmacological interventions for management of pain are mostly preferred because it is associated with minimal side-effects and improved rate of outcome. Ambrose and Golightly (2015) highlighted that physical exercise can be effectively used as non-pharmacological intervention for the chronic pain management. Observance of mild to moderate physical activity promotes sleep along with proper regulation of the blood flow throughout the body. This in turn helps in reducing the overall pain stimuli within the body. Ambrose and Golightly (2015) further highlighted that regular practice of physical activity helps in strengthening of the muscles, aerobic conditioning and improvement of the flexibility of the body, which helps in the overall reduction and effective management of chronic pain.

However, on another side, Ambrose and Golightly (2015) highlighted that at times persons, who are suffering from cancer; their physical condition is not suitable enough to perform daily physical activity. An ailing person or a terminally ill person may not be fit enough to indulge into physical activity. In that case pharmacological intervention for the pain management is the only effective way. It is also ethically approachable as it minimizes the pain. Eccleston, Morley and Williams (2013) highlighted psychological approaches as non-pharmacological interventions for the effective management of chronic pain. The psychological intervention mainly include highlighting mindfulness based therapy and cognitive improvement therapy.

These therapies help in the improvement of the overall mental state of the individual. For example, effective psychological interventions help in the improvement of anxiety and depression, which in turn help to reduce the overall stimulus of pain. This decrease in the pain stimulus helps in effective management of chronic pain and it is devoid of any side effects. Psychological interventions are at times proved to be effective for the management of chronic pain among the cancer patients. However, Eccleston, Morley and Williams (2013) highlighted that the use of proper psychological interventions along with the short term dosage of the mild to moderate opioid help to get better results and improved pain outcome.

Non-Pharmacological Interventions for Pain Management and Outcomes

Conclusion

Thus from the above discussion it can be concluded that opioids can be regarded as an important source of help in the effective management of chronic pain. Proper use of the opioids at regulated dosage and at regulated interval time helps in effective management of the chronic pain arising out the traumatic injury, bone fracture or chronic pain of cancer. However, analysis of the articles also highlighted that long-term use of opioid causes the body to adapt to those kind of pain management medications. As a result they bring less pain relief from the stipulated dosage of opioid. This phenomenon is known as tolerance. Increase in the opioid tolerance or dependence causesopioid addiction along with other associated side-effects like respiratory complications, cardiac failure and hormonal problems.

Thus it is the duty of the healthcare professionals to abide by the legislations and policies underlying the application of opioid in pain management in order to negate the chances of development of opioid tolerance. Non-pharmacological interventions like physical exercise or psychological therapies are at times successful in giving relief from pain. However, in case of cancer pain, these kind of non-pharmacological interventions are found to be ineffective. At the end, it can be clinched that opioid can be treated as the last resort for effective management of chronic pain when all other non-pharmacological interventions for pain management have failed. Moreover, instant relief or the fast action provided by opioid as an analgesic helps to provide patients instant relief from the debilitating experience of pain and thus can be regarded as help in chronic pain management.

References

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Chou, R., Turner, J. A., Devine, E. B., Hansen, R. N., Sullivan, S. D., Blazina, I., … & Deyo, R. A. (2015). The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Annals of internal medicine, 162(4), 276-286.

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Eccleston, C., Morley, S. J., & Williams, A. D. C. (2013). Psychological approaches to chronic pain management: evidence and challenges. British journal of anaesthesia, 111(1), 59-63.

Government of South Australia (2018). Opioids, when to prescribe. Access date: 26^th August. 2018.

Jamison, R. N., Kerry Anne Sheehan, B. A., Elizabeth Scanlan, N. P., & Ross, E. L. (2014). Beliefs and attitudes about opioid prescribing and chronic pain management: survey of primary care providers. Journal of opioid management, 10(6), 375-382.

Manglik, A., Lin, H., Aryal, D. K., McCorvy, J. D., Dengler, D., Corder, G., … & Huang, X. P. (2016). Structure-based discovery of opioid analgesics with reduced side effects. Nature, 537(7619), 185.

Nguyen, L. M., Rhondali, W., De la Cruz, M., Hui, D., Palmer, L., Kang, D. H., … & Bruera, E. (2013). Frequency and predictors of patient deviation from prescribed opioids and barriers to opioid pain management in patients with advanced cancer. Journal of pain and symptom management, 45(3), 506-516.