R.Ph.s feel pain of those on chronic opioid therapy

Web sites of interest

• American Pain Foundation http:// http://www.painfoundation.org/
• American Pain Society http:// http://www.ampainsoc.org/
• Pain and Policy Studies Group http:// http://www.medsch.wisc.edu/painpolicy/
• International Association for the Study of Pain http:// http://www.iasp-pain.org/
• The Mayday Pain Project http:// http://www.painandhealth.org/

Opioids decrease pain and improve functioning. But some patients are reluctant to take opioids because they want to "be engaged in life." So said Pharm.D. Suzanne Amato Nesbit, clinical pharmacy specialist in pain management and clinical coordinator of the cancer pain service at the Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins, Baltimore. She addressed a seminar on optimizing outcomes in patients on chronic opioid therapy, held last month outside New York City. The seminar was sponsored by Long Island University's Arnold & Marie Schwartz College of Pharmacy and Health Sciences. Nesbit reported that she and her staff often must remind patients that the goal of opioid therapy is to improve their quality of life by relieving pain and managing the debilitating adverse effects associated with opioids.

The healthcare team must together identify specific and realistic goals for patients with chronic pain, Nesbit continued. They should also determine the time frame in which each therapeutic goal can be reached using the most appropriate intervention.

Analgesics are chosen via a three-step continuum, from the treatment of mild pain using nonopioids to the relief of severe pain using both opioids and nonopioids along with adjuvant therapy. Patients taking fixed-dose opioid/acetaminophen or opioid/salicylic acid combinations may not need additional acetaminophen or ibuprofen.

Nesbit noted that healthcare providers are sometimes reluctant to start patients on opioid therapy because they are concerned about the risks of abuse and/or addiction. She mentioned that the incidence of addiction is very low but that many patients associate opioids with death and dying. "Opioids are appropriate throughout the continuum of disease," she said. "This represents an area where pharmacists can educate not just patients but also other healthcare providers."

Treatment-naïve patients should be started on a low dose of opioids. But medication to treat breakthrough pain should always be available. If a long-acting opioid is being used, Nesbit said, 10% to 30% of the scheduled dose is appropriate for breakthrough pain relief. The opioid dose should be titrated either until analgesia occurs or the adverse effects of the drugs become unmanageable. Decreasing the dose or rotating to another opioid is appropriate in patients experiencing sedation, nausea and vomiting, or constipation, she said. She recommended the concomitant use of methylphenidate, modafinil (Provigil, Cephalon), dextroamphetamine, caffeine, antiemetics, and laxatives. She added that for most stimulants, this represents an off-label use.

Nesbit urged pharmacists to consider disease progression and course of treatment when addressing cancer pain. She stated that pain control, total daily dose, use of breakthrough medications, and perceived or actual adverse effects should be regularly reassessed in all patients on opioids.