Principles of opioid maintenance analgesia for chronic pain

  1. Successful management of chronic pain usually does not require the use of opioids; however, some patients with chronic pain can benefit from long-term opioid maintenance analgesia (OMA). These patients function better, maintain improved pain control with acceptable side effects, and continue to use their medications in a responsible, reliable manner.
  2. In some patients, pain cannot be managed with long-term use of opioids. Pain control is marginal, function does not improve, side effects may prohibit ongoing therapy, or the patient’s abilityto keep medication use under control is poor or erratic.
  3. Opioids are rarely adequate as the sole treatment for complex chronic pain, which usually requires a multimodal and often a multidisciplinary approach.
  4. OMA for chronic pain is neither a patient’s right nor a privilege. It is one treatment approach that may be chosen by mutual agreement between patient and physician.
  5. Candidates for OMA should:
    • Have an established diagnosis that is concordant with moderate to severe pain
    • Be reliable patients who are known to the physician and are expected to be compliant with the treatment protocol
    • Have exhausted reasonable alternative treatments and be open to new ments in the future
    • Not be using illegal drugs
    • Not be pregnant or likely to become pregnant during the course of treatment
  6. Patients with a history of addiction or poor impulse control are at increased risk for failing to comply with an OMA regimen.
  7. For daily pain, long-acting opioids taken on a fixed schedule are generally preferred for OMA. Limited quantities of nonopioids or shorter-acting opioids are acceptable for breakthrough pain in some cases.
  8. For episodic pain, limited quantities of opioid analgesics may be prescribed as needed.
  9. Meperidine hydrochloride is a poor choice for OMA because of metabolite toxicity with repeated dosing.
  10. For patients initiating OMA, a signed agreement outlining expectations and responsibilities is recommended (see box below). Failure to comply with the agreement should result in discontinuation of OMA or actions to ensure compliance in the future.
  11. Continuation of OMA depends on the following five factors:
    • The medication is safe with acceptable side effects.
    • The medication is effective; that is, pain is reduced and function and quality of life are improved.
    • The patient is a reliable and responsible participant in the treatment program.
    • The condition causing pain persists.
    • No specific or better alternative treatments are available.
  12. The physician’s responsibilities for OMA include:
    • Initial assessment of the pain problem, including relevant medical, psychological, and social factors
    • Scheduling regular office visits for reassessing pain and related conditions; monitoring safety, efficacy, and compliance; and managing side effects
    • Being prepared to continue OMA when it is working
    • Being prepared to taper and discontinue OMAwhen it is not working
    • Thorough documentation of the responsibilities listed
  13. Techniques for monitoring compliance include:
    • Conducting patient interviews
    • Checking patient’s compliance with appoint-ments
    • Obtaining collateral information from family members, other physicians, nurses, and pharmacists
    • Obtaining pharmacy profiles
    • Scheduling drug screens
  14. When discontinuing OMA, the weaning schedule depends on daily dosage and duration of treatment. No weaning is needed when opioids havebeen used occasionally; daily opioid use may re-quire weaning that ranges from 10 days to a few months.
  15. Referral to a pain specialist for consideration of OMA is warranted when:
    • The cause of pain is unclear
    • Behavioral, psychological, and social factors complicate the pain problem
    • The physician is unsure what additional treatment may be effective, or how to administer such treatment

Adapted, with permission, from Fairview Pain Management Center, Minneapolis.

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