Saturday, February 13, 2010

Followup: Safety of Long-Term Opioid Therapy

The prescribing of opioid analgesics for chronic noncancer pain is still shrouded by some controversy; particularly, when patients are continued on these medications for many years. However, evidence is growing in support of long-term opioid therapy for providing less pain, better function, and improved quality of life in select patients. Benefits clearly may outweigh risks.

Last August, we reported on a study by Forest Tennant, MD, of 24 patients administered strong opioid analgesics for from 10 to 35 years [see blogpost 10+ Years on Opioid Analgesics! What Happens?]. Overall, he observed that patients experienced significant pain relief and ongoing quality of life and physical functioning enhancements. At the same time, there were relatively few complications of the therapy, which were easily managed. However, this was a quite limited cases series of patients.

Now, writing in the January/February 2010 edition of the journal Practical Pain Management, Tennant has expanded his study four-fold to include 100 patients [Tennant 2010]. Patients ranged in age from 30 to 83 years, were 61% male, and had been administered opioids for 10 to 35 years. Significant causes of chronic pain being treated with opioids included spine disease (51%), arthritis (16%), peripheral neuropathy (14%), and headache (10%). A majority were administered a single opioid (62%), with those most commonly prescribed being hydrocodone (56%), oxycodone (25%), fentanyl (15%), and morphine (13%) [exact formulations are not specified in the report]. Far from becoming debilitated by ongoing opioid therapy most patients were able to read newspapers and other literature (97%), attend social events (89%), dress themselves (82%), walk unassisted (85%), and even drive a car (74%). Almost half of patients (45%) had been on a stable opioid dose without significant escalation for at least 3 years (range 3 months – 31 years).

CAVEATS: It is of interest that significant numbers of patients were benefitting from long-term opioid therapy for headaches and peripheral neuropathy, since some guidelines and clinical literature argue against the value of opioid analgesia in aiding these conditions. Therefore, further research in much larger patient populations appears warranted to explore these applications of opioids before indisputably accepting perspectives in the literature.

Unfortunately, Tennant’s updated and expanded report does not comment on the full range of risk factors that might be of concern. In his original report on only 24 patients, he noted that some developed other conditions during long-term opioid therapy, including tachycardia, hypertension, hyperlipidemia, diabetes, tooth decay, and weight gain. These could be medically managed and whether the conditions were pain related, opioid induced, or simply inherent in the patients and/or a result of aging was unclear. No neurologic complications such as hyperalgesia, dementia, tremor, or seizures were noted; nor were hepatic, renal, or gastrointestinal complications, except for minor constipation.

Tennant rightly concedes that even his expanded study of 100 patients does not incorporate sophisticated epidemiological techniques or the prospective randomization of patients to long-term opioid therapy. It is more of a preliminary “proof of concept” than a clinical trial. He writes that this study, or survey, was merely intended to answer a fundamental question: “Are there chronic pain patients in the United States who have taken opioids over 10 years and report less pain, better function, and have a better quality of life?” The answer clearly is “Yes.” Might some of the patients have done just as well if treated by other pain management modalities? Possibly so. Are there some patients who would not respond or thrive as well on long-term opioid therapy as those in Tennant’s cohort? Probably so. At the same time, however, when patients appear to be doing well on opioid therapy for chronic noncancer pain, Tennant believes, “there is no obvious reason to discourage opioid use or encourage pain patients to cease opioids.”

Reference: Tennant F. Opioid treatment 10-year longevity survey. Final report. Prac Pain Manage. 2010;10(1):47-48.


Anonymous said...

Thank you Dr. Tennant for your contributions to the science of chronic pain management.

Anonymous said...

When I first began opioid therapy 15+ years ago, my pain doctor noted that I maybe one of those that had to be on opioids for the rest of my life. I was in my mid 30's at the time, and I was hoping that would not be the case.

Now, at 51, I still reamin, but unfortunatly have had to change physicians due to moving out of state for my husbands job, and the revolving door of doctors in the clinic I have been a patient at, for the last 7 yrs.

Each doctor has their own views, and while some are understanding and have no problems with prescribing as long as I am stable, the new doctor I have seen for the last 2 months, now thinks he knows me better then I know myself, and his job he says is to get me tapered and off the meds!! Although nothing has changed in my pain, and I have remained stable on the same meds for the last 10 yrs with tiny dose increases here and there, and NO behavior of drug seeking or addiction, his belief is that long term therapy is a danger for me...PERIOD. I think the real reason is, that he believes it is more of a danger to himself and the DEA.

So, I am happy to see that this may not be the case, and if push comes to shove, I will make him aware of this study...although, he's young, and thinks he knows better, much like my teenagers. :)

SB. Leavitt, MA, PhD said...

As with any other medications, if a patient can do well without the need for long-term opioids, and thrive, that could be preferred. Even in Dr. Tennant’s long-term patients there were, indeed, side effects that needed to be managed, so it wasn’t a perfect therapy. The real question in your case is, has this new, young doctor had great successes in tapering chronic pain patients off of their opioids -- ie, they are doing better without the meds -- or would you be a science experiment? -- SBL

Anonymous said...

I would like to comment on this. I am a pain patient who has been on pain medication for 20 years. I just found out that my hip pain was due to arthritis instead of fibromyalgia. My hip was severe and caused severe pain. I just had hip replacement surgery and am now cutting down on pain medication with no adverse reactions, no withdrawals. I will say that according to testing I am not an addictive personality. So pain medication was needed and without that medication I would not have had any quality of life for those 20 years. The head of my femur was worn half way down. I repeat the pain was severe.

I am Karen L. Simon and am puting my name in on purpose. Those who suffer from cronic pain are not drug addicts and should not be grouped with such.

Anonymous said...

As a pain patient who has been through nearly every painkiller and migraine "treatment you can name, as well as chiropractic, massage therapy, yoga, changing diet, etc, etc. I can definitively say that, in my case, at least, opoids are the only medications that were both effective and well-tolerated, with the only real side effect being drowsiness.
Due to a change in doctors, I'm now off of opoids. I expirienced no withdrawl what so ever (if you want a tough withdrawl, try SSRI's, Dr. Leavitt).
In the course of a month I've gone from being able to function at close to "normal" levels to being bed-ridden 3-4 days a week, have lost 10 lbs, and often can't get to sleep, or am awoke in my sleep. Which has lead to 3 ER visits, and a resurgance of depression. Not to mention a near-complete halt to avtivities or productivity.
As I said to my new Dr, I sincerely hope that if you ever find yourself in my shoes, you will be able to find someone who will treat you with the respect and compassion that you have failed to show me.

Anonymous said...

I finally had my life back working with Dr. and N.P. at The Medical Center that has treated my conditions for the past 7 years. Last week the receptionist called me and give me less than 30 days to find a new pain clinic/doctor. Contrary to what most people will automatically jump to, I am a compliant patient, take my meds as ordered, passed all drug tests and now I have been tossed aside. Small town, nowhere to go.

Anonymous said...

Dr. Tennant,
This was a excellent study and I enjoyed reading it. I have been suffering form cervical pain for 27 years now and the aggressive opioid therapy I'm on has been great. It has allowed me to live a normal life and Advocate for other in severe chronic pain.
Thanks for your hard work,

Mark S. Barletta
Pain Advocate