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 Table of Contents  
EDITORIAL
Year : 2018  |  Volume : 32  |  Issue : 2  |  Page : 57-59

At the opioid crossroad for chronic non cancer pain


Department of Anaesthesiology, King Edward Memorial Hospital and Seth Gordhandas Sunderdas Medical College, Mumbai, Maharashtra, India

Date of Web Publication31-Aug-2018

Correspondence Address:
Dr. Sweta Salgaonkar
1003, Jasmine, Neelkanth Gardens, Govandi (East), Mumbai, Maharashtra 400088
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijpn.ijpn_34_18

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How to cite this article:
Salgaonkar S. At the opioid crossroad for chronic non cancer pain. Indian J Pain 2018;32:57-9

How to cite this URL:
Salgaonkar S. At the opioid crossroad for chronic non cancer pain. Indian J Pain [serial online] 2018 [cited 2018 Nov 13];32:57-9. Available from: http://www.indianjpain.org/text.asp?2018/32/2/57/240284

Opioids are considered the pinnacle of pain management especially for severe pain and cancer pain.[1],[2],[3],[4] Severe systemic complications seen with the long-term nonsteroidal anti-inflammatory medications and interventional procedures for chronic non cancer pain probably prompted pain physicians to choose opioids as the possible pain relievers in the last decade of twentieth century. Pharmaceutical industry–driven campaigns underplayed the risks of long-term opioids. Societal and organizational recommendations and advocacy groups misguided the physicians and patients in prescribing opioids in desperate attempts to control chronic pain and in demanding complete pain relief, respectively.[5]

The physicians were educated to overcome the so-called “opiophobia.” Easy availability and relaxed prescribing guidelines and expensive pain interventions in the western part of the world soon resulted in millions of opioid prescriptions. The latter created a “feel-good effect” in the patients having chronic pain, which was a huge burden on the health care, society, and economy. A study published by Joranson et al.[6] in JAMA concluded that the trend of increasing medical use of opioid analgesics to treat pain did not appear to contribute to the increase in the health consequences of opioid analgesic abuse. Opioids made all stakeholders happy, though the happiness was only short-lived as it bore severe consequences.

The prescribed opioids resulted in overdose deaths, dependence, and abuse in the western continents of the world. Rates of opioid use disorder and opioid overdose deaths reached unprecedented levels over the past two decades.[7] Opioid overdoses were responsible for deaths of more than 42,000 Americans in 2016. The damages also included the increased demand for emergency and health-care services, increased crime and need for law enforcement, broken families, and poor economic productivity,[8],[9] not to mention the millions spent by the US government on managing opioid-related side effects. Liberal prescription of opioids for pain management, thus, created a havoc, a mayhem; and the statisticians suspect that the worst is yet to come. Lawful prescriptions introduced more and more patients with chronic non cancer pain to opioids leading to dependence, which in turn pushed them into illicit use of opioids or related drugs that were available much cheaper.

In India, access to opioids is guarded for all stakeholders that include patients, physicians, pharmacists, transporters, and manufacturers. The per capita consumption of opioids is so low that there are ethical concerns regarding the rights of pain relief, especially, in patients with cancer.[10] This led to the revision of Narcotic Drugs and Psychotropic Substances (NDPS) Act in 2014 by the professionals and policy makers. India had no legislation regarding narcotics until 1985. The NDPS Act came into force on November 14, 1985, and has since been amended thrice–in 1988, 2001, and 2014. In 2014, the amended act recognized the need for pain relief as an important obligation of the government. It created a class of medicines called the “essential narcotic drugs” that included six drugs, namely morphine, fentanyl, methadone, oxycodone, codeine, and hydrocodone.[10] Recently, tramadol has been covered under the NDPS Act in view of the impending abuse and addiction threat especially in the Asian countries.[11] The published gazette created a lot of disappointment among the practicing pain physicians. Tramadol is one of the cheapest opioid available to the physicians and patients.

The pain physicians in India are made aware of the US opioid crisis as the topic is discussed in every local, regional, and national conference. Fentanyl, the synthetic opioid, is at the center of the opioid crisis in the United States. China is the major supplier of fentanyl to the United States, Canada, and Mexico.[12] Six US states have declared public health emergency to combat opioid crisis. Trump Government approved death sentence for illegal opioid traffickers, and included naloxone in the resuscitation cart.

Indian pain physicians are not aware about the so-called “weak” tramadol causing slow dependence and abuse in the Asian countries, especially, the Middle East and Africa. It is this less-potent opioid, tramadol, and not fentanyl, which is responsible for the opioid crisis here, and India is its biggest supplier.

Indian pain physicians and for that matter, globally, all pain physicians are at the crossroad whether to prescribe opioids or not for chronic non cancer pain. Of course, the answer is not a simple yes or no. Centers for Disease Control and Prevention (CDC) Guidelines have empowered the pain physicians to use their clinical judgment and justification on a patient-to-patient basis rather than a blanket recommendation. As high dosage opioids (>90 MME, milligram morphine equivalent/day) were the primary findings with deaths, the CDC Guidelines recommended non-pharmacologic and non-opioid therapy as the preferred treatment option for chronic non cancer pain. Opioids should only be used when the benefits for pain and functionality outweigh the risks. The providers should establish realistic treatment goals and prescribe immediate release opioids instead of long-acting opioids. The physicians must evaluate the risks related to harm and screen patients if they are on other sedative group of drugs or substance abuse. Patients should be under drug monitoring program with the strategy of “start low and go slow.”[8]

There are a few observations in the Indian population regarding chronic pain. Indians develop a higher tolerance to pain and thus have less of a need to manage their pain with opioids. Also, unlike patients in the United States, who are more likely to use medication as a first-line treatment, Indian patients often approach chronic pain issues by making lifestyle modifications or utilizing alternative therapies before turning to medications.

Some more thoughts for the physicians prescribing opioids for chronic non cancer pain:

  • Dishing out the same prescription of opioids, visit after visit is easy but dangerous. Smart use of opioids giving break with nonsteroidal anti-inflammatory drugs, if no contraindications, and with organ function monitoring, could be considered to prevent opioid dependence.
  • A combination of non-pharmacotherapy in the form of counseling, physiotherapy, cognitive behavioral therapy, and mindfulness[7] must be incorporated in the management regimen. Multimodal pharmacotherapy and interventions to maximize pain relief and functionality and minimize side effects must be designed for individual patients. Interventions may include image-guided nerve blocks, regenerative therapy, intramuscular needling, fascial release, and many more.
  • Designing personalized activities and going all the way to improve patients' involvement and compliance is a physician's responsibility for better pain control.
  • Realistic expectations and involvement of family and society for support must be encouraged. Positive acceptance from the patient goes a long way in managing pain.[8]
  • Being humorous and lighthearted helps in diffusing the stress of chronic pain.[13],[14]
  • Giving titration of the medications in the hands of the patients with awareness about the side effects makes them empowered with decision making in their own pain management protocol.[15]
  • Incorporation of spiritual aspect of pain: knowledge must be shared to get all pain management therapies work better and for longer time.[16] Improving spiritual goals in life through slow and consistent transformation must be insisted for better pain control and improved quality of life.
  • Following proper documentation and national guidelines in this regard will only help avoid opioid abuse.


Incorporation of the aforementioned strategies will create a strong physician–patient bond that will not only avoid drug-seeking tendency in a patient but also pick up if any, in a busy clinic, where drug monitoring might be difficult, unreliable, and expensive.


  Summary Top


Research in better understanding of neurobiology of pain, and clinical trials involving non-pharmacotherapy techniques will help to formulate effective guidelines that can help large population of chronic non cancer pain without much safety concerns. It is the need of the hour that scientists and researchers in pain medicine explore the spiritual aspects of pain, which is the basis of cognitive behavioral therapy and mindfulness, the practice that is followed in many religions of Asian countries. Over-reliance on opioids and pharmacotherapy for chronic non cancer pain will surely have safety concerns in long-term use.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Acute Pain Management Guideline Panel. Acute pain management: operative or medical procedures and trauma. In: Clinical practice guideline. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, US Department of Health and Human Services; 1992. AHCPR publication 92-0032.  Back to cited text no. 1
    
2.
Jacox A, Carr DB, Payne R. Management of cancer pain. In: Clinical practice guideline, number 9. Rockville, MD: Agency for Health Care Policy and Research, US Department of Health and Human Services, Public Health Service; 1994. AHCPR publication 94-0592.  Back to cited text no. 2
    
3.
World Health Organization. Cancer pain relief. Geneva, Switzerland: World Health Organization; 1986.  Back to cited text no. 3
    
4.
Doyle D, Hanks GWC, MacDonald N. Oxford textbook of palliative medicine. New York, NY: Oxford University Press; 1993.  Back to cited text no. 4
    
5.
Jones MR, Viswanath O, Peck J, Kaye AD, Gill JS, Simopoulos TT. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther 2018 Apr 24. doi: 10.1007/s40122-018-0097-6. [Epub ahead of print]  Back to cited text no. 5
    
6.
Joranson DE, Ryan KM, Gilson AM, Dahl JL. Trends in medical use and abuse of opioid analgesics JAMA 2000;283:1710-4.  Back to cited text no. 6
    
7.
National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Board on Health Sciences Policy; Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse; Bonnie RJ, Ford MA, Phillips JK, Editors. Pain management and the opioid epidemic: balancing societal and individual benefits and risks of prescription opioid use. Washington, DC: National Academies Press; 2017.  Back to cited text no. 7
    
8.
CDC US health department guidelines. CDC guideline for prescribing opioids for chronic pain. Available from: www.cdc.gov/drugoverdose/prescribing/guideline.html [Last accessed on 2017 August].  Back to cited text no. 8
    
9.
Ostling PS, Davidson KS, Anyama BO, Helander EM, Wyche MQ, Kaye AD. America’s opioid epidemic: a comprehensive review and look into the rising crisis. Curr Pain Headache Rep 2018; 22:32.  Back to cited text no. 9
    
10.
Vallath N, Rajagopal MR, Tandon T. Guideline for stocking and dispensing essential narcotic drugs in medical institutions. Available from: https://tmc.gov.in/ncg/images/Guidelines_for_stocking_and_Dispensing_ENDs_in_Medical_Institutions.pdf [Last accessed on 2017 August].   Back to cited text no. 10
    
11.
Government circular Gazette. Available from: http://dor.gov.in/sites/default/files/Essential%20Narcotic%20Drug%20Notification%20dated%2005%2005%202015_0.pdf [Last accessed on 2015 May].  Back to cited text no. 11
    
12.
Claire F. The U.S. opioid epidemic. Available from: https://www.cfr.org/backgrounder/us-opioid-epidemic [Last accessed on 2017 December].  Back to cited text no. 12
    
13.
Bhatia J. Eliminating stress brings pain relief. Available from: https://www.everydayhealth.com/pain-management/stress-and-pain.aspx [Last accessed on 2013 February].  Back to cited text no. 13
    
14.
Benjamin C. Pain and your emotions. Available from: https://medlineplus.gov/ency/patientinstructions/000417.htm [Last accessed on 2017 July].  Back to cited text no. 14
    
15.
LeFort SM, Gray-Donald K, Rowat KM, Jeans ME. Randomized controlled trial of a community-based psychoeducation program for the self-management of chronic pain. Pain 1998;74:297-306.  Back to cited text no. 15
    
16.
Puchalski CM. The role of spirituality in health care. Proc (Bayl Univ Med Cent) 2001;14:352-7.  Back to cited text no. 16
    




 

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