"My life is under control with these medications": an interpretative phenomenological analysis of managing chronic pain with opioids.

BACKGROUND: The use of opioids to relieve chronic pain has increased during the last decades, but experiences of chronic opioid therapy (COT) (> 90 days) point at risks and loss of beneficial effects. Still, some patients report benefits from opioid medication, such as being able to stay at work. Guidelines for opioid use in chronic pain do not consider the individual experience of COT, including benefits and risks, making the first person perspective an important scientific component to explore. The aim of this study was to investigate the lived experience of managing chronic pain with opioids in a sample who have severe chronic pain but are able to manage their pain sufficiently to remain at work. METHODS: We used a qualitative research design: interpretative phenomenological analysis. Ten individuals with chronic pain and opioid therapy were purposively sampled in Swedish tertiary care. RESULTS: Three super-ordinate themes emerged from the analyses: Without opioids, the pain becomes the boss; Opioids as a salvation and a curse, and Acknowledgement of the pain and acceptance of opioid therapy enables transition to a novel self. The participants used opioids to regain control over their pain, thus reclaiming their wanted life and self, and sense of control over one's life-world. Using opioids to manage pain was not unproblematic and some of the participants had experienced a downward spiral of escalating pain and uncontrollable opioid use, and stigmatisation. CONCLUSIONS: All participants emphasised the importance of control, regarding both pain and opioid use. To accomplish this, trust between participants and health care providers was essential for satisfactory treatment. Regardless of the potential sociocultural benefits of staying at work, participants had experiences of balancing positive and negative effects of opioid therapy, similar to what previous qualitative research has found. Measurable improvement of function and quality of life, may justify the long-term use of opioids in some cases. However, monitoring of adverse events should be mandatory. This requires close cooperation and a trusting relationship between the patients and their health care provider.

A case of severe low back pain after surgery.

The etiology of chronic back pain is often unknown but can include failed spinal surgery. Pain can often be of mixed type and it is important to evaluate pain mechanisms. Comorbid factors often contribute to pain chronicity. Multimodal treatment, including opioid rotation where indicated, may offer a successful management approach. Other rehabilitative procedures such as physiotherapy, exercise therapy, and good sleep hygiene may have a profound impact on patient quality of life. Spinal cord stimulation may be an effective option for some patients with failed spinal surgery syndrome. A case of severe low back pain after surgery in a 45-year-old man is presented to illustrate this.

Successful management of chronic pelvic pain.

Chronic pelvic pain is a common, multifactorial complaint that affects both women and men, causing disability and frustration for patients. The exact aetiology remains unknown, although several theories have been proposed. Assessment should be undertaken with care and compassion, while considering the sensitive nature of the area. Management involves ruling out treatable pathology concomitant with strategies to control pain. Novel treatment approaches have been investigated for specific clinical scenarios. The more severe CPP cases are best managed using a multidisciplinary approach. Management requires good integration and knowledge of all pelvic organ systems and including musculoskeletal, neurologic and psychological mechanisms.

Pharmacological treatment patterns in neuropathic pain--lessons from Swedish administrative registries.

OBJECTIVE: To explore the treatment patterns of patients with a diagnosis related to chronic pain (DRCP) initiating pharmacological treatment indicated for neuropathic pain (NeuP: tricyclic antidepressants, serotonin-norepinephrine reuptake inhibitors, and anticonvulsants). DESIGN: Retrospective study on administrative registers. SETTING: General population in Western Sweden (one sixth of the country). SUBJECTS: All patients with a DRCP (N = 840,000) in years 2004-2009. OUTCOME MEASURES: Treatment sequence, continuation, switching, and comedication. RESULTS: In total, 22,997 patients with a first NeuP in 2007 or 2008 were identified, out of which 2% also had epilepsy and 39% had a mood disorder. The remaining 13,749 patients were assumed to be treated for neuropathic pain, out of which 16% had a neuropathy diagnosis, 18% had a mixed pain diagnosis, and the remaining 66% had another DRCP. The most common first prescription was amitriptyline (40%) followed by pregabalin (22%) and gabapentin (19%). More than half had discontinued treatment after 3 months, and 60-70% at 6 months. Seven percent received another NeuP drug within 6 months of the discontinuation of their first NeuP treatment, 11% had another analgesic and 22% had a prescription indicating psychiatric comorbidity (selective serotonin reuptake inhibitors or benzodiazepine). CONCLUSIONS: Treatment initiation of currently available drugs indicated for neuropathic pain less frequently lead to long-term treatment in clinical practice compared with clinical trial, and few try more than one drug. We suggest our findings to be indications of a need for better routines in diagnosing patients to ascertain optimal treatment and follow-up.

Combined analysis of circulating ß-endorphin with gene polymorphisms in OPRM1, CACNAD2 and ABCB1 reveals correlation with pain, opioid sensitivity and opioid-related side effects.

BACKGROUND: Opioids are associated with wide inter-individual variability in the analgesic response and a narrow therapeutic index. This may be partly explained by the presence of single nucleotide polymorphisms (SNPs) in genes encoding molecular entities involved in opioid metabolism and receptor activation. This paper describes the investigation of SNPs in three genes that have a functional impact on the opioid response: OPRM1, which codes for the µ-opioid receptor; ABCB1 for the ATP-binding cassette B1 transporter enzyme; and the calcium channel complex subunit CACNA2D2. The genotyping was combined with an analysis of plasma levels of the opioid peptide ß-endorphin in 80 well-defined patients with chronic low back pain scheduled for spinal fusion surgery, and with differential sensitivity to the opioid analgesic remifentanil. This patient group was compared with 56 healthy controls. RESULTS: The plasma ß-endorphin levels were significantly higher in controls than in pain patients.A higher incidence of opioid-related side effects and sex differences was found in patients with the minor allele of the ABCB1 gene. Further, a correlation between increased opioid sensitivity and the major CACNA2D2 allele was confirmed. A tendency of a relationship between opioid sensitivity and the minor allele of OPRM1 was also found. CONCLUSIONS: Although the sample cohort in this study was limited to 80 patients it appears that it was possible to observe significant correlations between polymorphism in relevant genes and various items related to pain sensitivity and opioid response. Of particular interest is the new finding of a correlation between increased opioid sensitivity and the major CACNA2D2 allele. These observations may open for improved strategies in the clinical treatment of chronic pain with opioids.

Opioid endocrinopathy: a clinical problem in patients with chronic pain and long-term oral opioid treatment.

BACKGROUND: The use of strong opioids for treatment of noncancer chronic pain has increased. However, strong evidence for sustained pain relief and improved function is lacking. Controversy prevails, whether hormonal changes are induced by long-term treatment with opioids. The purpose of this study was to investigate the occurrence of endocrine dysfunction in chronic pain patients on long-term opioid treatment. METHODS: A study group of 39 chronic pain patients treated with strong oral opioids for more than 1 year was compared with a control group of 20 chronic pain patients without opioid treatment. Basic levels of prolactin and function of the hypothalamic-pituitary-thyroid-, hypothalamic-pituitary-adrenal-axis, and hypothalamic-pituitary-growth-hormone - and hypothalamic-pituitary-gonadal-axis were measured. Quality-of-life and side effects were estimated with EORTC-QLQ-C30. RESULTS: In the opioid-treated group, the patients had signs of pituitary dysfunction affecting all axes. Significant differences were shown in hypofunction of the hypothalamic-pituitary-gonadal -axis, hyperfunction of the hypothalamic-pituitary-adrenal -axis, and higher prolactin levels in the opioid-treated group, compared with the control group. The degree of pain was rated the same in both groups, but the opioid-treated group reported more side effects and lower quality of life. CONCLUSIONS: Long-term treatment of chronic pain with strong opioids causes side effects that can be attributed to hormonal abnormalities caused by opioid-induced inhibition of hypothalamic-pituitary function. Hormone substitution can be indicated to treat symptoms. Decreasing the opioid dose or stopping the opioid treatment can reverse endocrine dysfunction. This needs to be recognized by all practitioners treating chronic pain patients with opioids.

Genetics and pain.

Progress in our understanding of the roles of genetics in pain and its management is described. New techniques are discussed, along with some potential uses of gene therapy. Relative gene expression, polymorphisms, and specific genes that influence interindividual responses to pharmacotherapy for pain are described.

Prescribing policies of opioids for chronic pain.

The prescription of opioids often poses a difficult problem for the practitioner, particularly when they are confronted with institutionalised fears and restrictive regulations. This article compares prescribing policies for opioids in three European countries, Austria, Israel and Portugal.

The rise of opiophobia: is history a barrier to prescribing?

A brief history of opiophobia and its effect on prescribing of opioid analgesics is presented. Barriers to opioid prescribing and additional readings on the topic are described.