European Pain Federation position paper on appropriate opioid use in chronic pain management

T O'Brien, L L Christrup, A M Drewes, M T Fallon, H G Kress, H J McQuay, G Mikus, B J Morlion, J Perez-Cajaraville, E Pogatzki-Zahn, G Varrassi, J C D Wells, T O'Brien, L L Christrup, A M Drewes, M T Fallon, H G Kress, H J McQuay, G Mikus, B J Morlion, J Perez-Cajaraville, E Pogatzki-Zahn, G Varrassi, J C D Wells

Abstract

Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non-specialist opioid prescribers. There is much confusing and conflicting information available to non-specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi-faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non-specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe.

Significance: This position paper provides expert recommendations for primary care physicians and other non- specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi-faceted approach to pain management, in properly selected and supervised patients.

© 2016 The Authors. European Journal of Pain published by John Wiley & Sons Ltd on behalf of European Pain Federation - EFIC®.

Figures

Figure 1
Figure 1
The multi‐dimensional concept of ‘total pain’.
Figure 2
Figure 2
A step‐by‐step guide to the initiation of opioid analgesia.
Figure 3
Figure 3
Algorithm to treat opioid induced constipation and bowel dysfunction. The arrows indicate failure of the first recommendation and thus continuation to next step. Treatment goals are to establish regular bowel function and eliminate upper gastrointestinal symptoms, improve QoL and avoid complications, such as haemorrhoids, rectal prolapse and faecal impaction. As support for clinical evaluation questionnaires such as the Bowel Function Index may be used, where a score >30 should lead to more intensive treatment.

References

    1. Ahmedzai, S.H. , Nauck, F. , Bar‐Sela, G. , Bosse, B. , Leyendecker, P. , Hopp, M. (2012). A randomized, double‐blind, active‐controlled, double‐dummy, parallel‐group study to determine the safety and efficacy of oxycodone/naloxone prolonged‐release tablets in patients with moderate/severe, chronic cancer pain. Palliat Med 26, 50–60.
    1. Akbarali, H.I. , Inkisar, A. , Dewey, W.L. (2014). Site and mechanism of morphine tolerance in the gastrointestinal tract. Neurogastroenterol Motil 26, 1361–1367.
    1. Alford, D.P. (2016). Opioid prescribing for chronic pain – achieving a right balance through education. N Engl J Med 374, 301–303.
    1. Amato, J.N. , Marie, S. , Lelong‐Boulouard, V. , Paillet‐Loilier, M. , Berthelon, C. , Coquerel, A. , Denise, P. , Bocca, M.L. (2013). Effects of three therapeutic doses of codeine/paracetamol on driving performance, a psychomotor vigilance test, and subjective feelings. Psychopharmacology 228, 309–320.
    1. American Pain Society Quality of Care Committee (1995). Quality improvement guidelines for the treatment of acute pain and cancer pain. JAMA 274, 1874–1880.
    1. Anderson, K.O. (2010). The assessment of cancer pain: Measurement strategy In Cancer Pain: Assessment and Management, Bruera E.D., Protenoy R.K., eds. (Cambridge: Cambridge University Press; ) pp. 89–104.
    1. Anderson, K.O. , Mendoza, T.R. , Valero, V. , Richman, S.P. , Russell, C. , Hurley, J. , DeLeon, C. , Washington, P. , Palos, G. , Payne, R. , Cleeland, C.S. (2000). Minority cancer patients and their providers: Pain management attitudes and practice. Cancer 88, 1929–1938.
    1. Anderson, K.O. , Richman, S.P. , Hurley, J. , Palos, G. , Valero, V. , Mendoza, T.R. , Gning, I. , Cleeland, C.S. (2002). Cancer 94, 2295–2304.
    1. Atluri, S.L. , Sudarshan, G. (2004). Development of a screening tool to detect the risk of inappropriate prescription opioid use in patients with chronic pain. Pain Physician 7, 333–338.
    1. Atluri, S. , Akbik, H. , Sudarshan, G. (2012). Pain prevention of opioid abuse in chronic non‐cancer pain: An algorithmic, evidence based approach. Pain Physician 15, ES177–ES189.
    1. Belgrade, M.J. , Schamber, C.D. , Lindgren, B.R. (2006). The DIRE score: Predicting outcomes of opioid prescribing for chronic pain. J Pain 7, 671–681.
    1. Bell, T.J. , Panchal, S.J. , Miaskowski, C. , Bolge, S.C. , Milanova, T. , Williamson, R. (2009). The prevalence, severity, and impact of opioid‐induced bowel dysfunction: Results of a US and European Patient Survey (PROBE 1). Pain Med 10, 35–42.
    1. Bosilkovska, M. , Walder, B. , Besson, M. , Daali, Y. , Desmeules, J. (2012). Analgesics in patients with hepatic impairment. Drugs 72, 1645–1669.
    1. Breivik, H. , Collett, B. , Ventafridda, V. , Cohen, R. , Gallacher, D. (2006). Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur J Pain 10, 287–333.
    1. Breivik, H. , Eisenberg, E. and O'Brien, T. , OPENMinds . (2013). The individual and societal burden of chronic pain in Europe: the case for strategic prioritisation and action to improve knowledge and availability of appropriate care. BMC Public Health 13, 1229.
    1. Brenner, D.M. , Chey, W.D. (2014). An evidence‐based review of novel and emerging therapies for constipation in patients taking opioid analgesics. Am J Gastroenterol Suppl 2, 38–46.
    1. Brock, C. , Olesen, S.S. , Olesen, A.E. , Frøkjær, J.F. , Andresen, T. , Drewes, A.M. (2012). Opioid‐induced bowel dysfunction: Pathophysiology and management. Drugs 72, 1847–1865.
    1. Brunton L., Chabner B., Knollmann B., eds. (2011). Goodman & Gilman's The Pharmacological Basis of Therapeutics 12th Edition. (New York, NY: McGraw‐Hill; ). Chapter 119. Opiates and Opioids; Chapter 207. Morphine.
    1. Camilleri, M. , Drossman, D.A. , Becker, G. , Webster, L.R. , Davies, N. , Mawe, G.M. (2014). Emerging treatments in neurogastroenterology: A multidisciplinary working group consensus statement on opioid‐induced constipation. Neurogastroenterol Motil 26, 1386–1395.
    1. Candy, B. , Jones, L. , Goodman, M.L. , Drake, R. , Tookman, A. (2011). Laxatives or methylnaltrexone for the management of constipation in palliative care patients. Cochrane Database Syst Rev 1, CD003448.
    1. Cherny, N.I. , Baselga, J. , de Conno, F. , Radbruch, L. (2010). Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in Europe – a report from ESMO and EAPC opioid policy initiative. Ann Oncol 21, 615–626.
    1. Chey, W.D. , Webster, L. , Sostek, M. , Lappalainen, J. , Barker, P.N. , Tack, J. (2014). Naloxegol for opioid‐induced constipation in patients with noncancer pain. N Engl J Med 370, 2387–2396.
    1. Chou, R. , Fanciullo, G.J. , Fine, P.G. , Adler, J.A. , Ballantyne, J.C. , Davies, P. , Donovan, M.I. , Fishbain, D.A. , Foley, K.M. , Fudin, J. , Gilson, A.M. , Kelter, A. , Mauskop, A. , O'Connor, P.G. , Passik, S.D. , Pasternak, G.W. , Portenoy, R.K. , Rich, B.A. , Roberts, R.G. , Todd, K.H. , Miaskowski, C. ; American Pain Society‐American Academy of Pain Medicine Opioids Guidelines Panel (2009). Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 10, 113–130.
    1. Cleeland, C.S. , Janjan, N.A. , Scott, C.B. , Seiferheld, W.F. , Curran, W.J. (2000). Cancer pain management by radiotherapists: A survey of radiation therapy oncology group physicians. Int J Radiat Oncol Biol Phys 47, 203–208.
    1. Coller, J.K. , Christrup, L.L. , Somogyi, A. (2009). Role of active metabolites in the use of opioids. Eur J Clin Pharmacol 65, 121–139.
    1. Corsenac, P. , Lagarde, E. , Gadegbeku, B. , Delorme, B. , Tricotel, A. , Castot, A. , Moore, N. , Philip, P. , Laumon, B. , Orriols, L. (2012). Road traffic crashes and prescribed methadone and buprenorphine: A French registry‐based case‐control study. Drug Alcohol Depend 123, 91–97.
    1. Cran, A. , Kiely, F. , O'Brien, T. (2014). Auditory symptoms as an unrecognised manifestation of opioid toxicity: Two case reports. J Pain Palliat Care Pharmacother 28, 378–381.
    1. Dagtekin, O. , Gerbershagen, H.J. , Wagner, W. , Petzke, F. , Radbruch, L. , Sabatowski, R. (2007). Assessing cognitive and psychomotor performance under long‐term treatment with transdermal buprenorphine in chronic non‐cancer pain patients. Anesth Analg 105, 1442–1448.
    1. Dalal, S. , Bruera, E. (2012). Assessing cancer pain. Curr Pain Headache Rep 16, 314–324.
    1. Dar, R. , Beach, C.M. , Barden, P.L. , Cleeland, C.S. (1992). Cancer pain in the marital system: A study of patients and their spouses. J Pain Symptom Manage 7, 87–93.
    1. Diego, L. , Atayee, R. , Helmons, P. , Hsiao, G. , von Gunten, C.F. (2011). Novel opioid antagonists for opioid‐induced bowel dysfunction. Expert Opin Investig Drugs 20, 1047–1056.
    1. Dorn, S. , Lembo, A. , Cremonini, F. (2014). Opioid‐Induced bowel dysfunction: Epidemiology, pathophysiology, diagnosis, and initial therapeutic approach. Am J Gastroenterol Suppl 2, 31–37.
    1. Drewes, A.M. , Jensen, R.D. , Nielsen, L.M. , Droney, J. , Christrup, L.L. , Arendt‐Nielsen, L. , Riley, J. , Dahan, A. (2013). Differences between opioids: Pharmacological, experimental, clinical and economical perspectives. Br J Clin Pharmacol 75, 60–78.
    1. Drewes, A.M. , Munkholm, P. , Simrén, M. , Breivik, H. , Kongsgaard, U.E. , Hatlebakk, J.G. , Agreus, L. , Christrup, L.L. (2016). Definition, diagnosis and treatment strategies for opioid‐induced bowel dysfunction – recommendations of the Nordic Working Group. Scand J Pain 16, 11–22.
    1. Dubois, S. , Bédard, M. , Weaver, B. (2010). The association between opioid analgesics and unsafe driving actions preceding fatal crashes. Accid Anal Prev 42, 30–37.
    1. Fine, P.G. , Portenoy, R.K. ; Ad Hoc Expert Panel on Evidence Review and Guidelines for Opioid Rotation (2009). Establishing “best practices” for opioid rotation: Conclusions of an expert panel. J Pain Symptom Manage 38, 418–425.
    1. Gilson, A.M. , Maurer, M.A. , Ryan, K.M. , Skemp‐Brown, M. , Husain, A. , Cleary, J. (2011). Ensuring patient access to essential medicines while minimising harmful use: A revised World Health Organization tool to improve national drug control policy. J Pain Palliat Care Pharmacother 25, 246–251.
    1. Gretton, S.K. , Droney, J. (2014). Splice variation of the μ receptor and its effect on the action of opioids. Br J Pain 8, 133–138.
    1. Haffey, F. , Brady, R.R. , Maxwell, S. (2013). A comparison of the reliability of smartphone apps for opioid conversion. Drug Saf 36, 111–117.
    1. Häuser, W. , Bock, F. , Engeser, P. , Tölle, T. , Willweber‐Strumpf, A. , Petzke, F. (2014). Long‐term opioid use in non‐cancer pain. Dtsch Arztebl Int 111, 732–740.
    1. Häuser, W. , Klose, P. , Welsch, P. , Petzke, F. , Nothacker, M. , Kopp, I. (2015). Methodology of the development of the updated LONTS guidelines for long‐term administration of opioids in noncancer pain]. [Article in German]. Schmerz 29, 8–34.
    1. Holzer, P. (2004). Pharmacology of opioids and their effects on gastrointestinal function. Am J Gastroenterol Suppl 2, 9–16.
    1. Holzer, P. (2009). Opioid receptors in the gastrointestinal tract. Regul Pept 155, 11–17.
    1. Kalso, E. , Edwards, J.E. , Moore, R.A. , McQuay, H.J. (2004). Opioids in chronic non‐cancer pain: Systematic review of efficacy and safety. Pain 112, 372–380.
    1. King, S. , Forbes, K. , Hanks, G.W. , Ferro, C.J. , Chambers, E.J. (2015). A systematic review of the use of opioid medication for those with moderate to severe cancer pain and renal impairment. A European Palliative Care Research Collaborative opioid guidelines project. Palliat Med 25, 525–552.
    1. Kress, H.G. , Kraft, B. (2005). Opioid medication and driving ability. Eur J Pain 9, 141–144.
    1. Laugsand, E.A. , Kaasa, S. , Klepstad, P. (2011). Management of opioid‐induced nausea and vomiting in cancer patients: Systematic review and evidence‐based recommendations. Palliat Med 25, 442–453.
    1. Leppert, W. (2014). Oxycodone/naloxone in the management of patients with pain and opioid–induced bowel dysfunction. Curr Drug Targets 15, 124–135.
    1. Löwenstein, O. , Leyendecker, P. , Hopp, M. , Schutter, U. , Rogers, P.D. , Uhl, R. , Bond, S. , Kremers, W. , Nichols, T. , Krain, B. , Reimer, K. (2009). Combined prolonged‐release oxycodone and naloxone improves bowel function in patients receiving opioids for moderate‐to‐severe non‐malignant chronic pain: A randomised controlled trial. Expert Opin Pharmacoher 10, 531–543
    1. Meissner, W. , Leyendecker, P. , Mueller‐Lissner, S. , Nadstawek, J. , Hopp, M. , Ruckes, C. , Wirz, S. , Fleischer, W. , Reimer, K. (2009). A randomized controlled trial with prolonged‐release oral oxycodone and naloxone to prevent and reverse opioid‐induced constipation. Eur J Pain 13, 56–64.
    1. Mularski, R.A. , White‐Chu, F. , Overbay, D. , Miller, L. , Asch, S.M. , Ganzini, L. (2006). Measuring pain as the 5th vital sign does not improve quality of pain management. J Gen Intern Med 21, 607–612.
    1. Pappagallo, M. (2001). Incidence, prevalence, and management of opioid bowel dysfunction. Am J Surg 182, S11–S18.
    1. Pathan, H. , Williams, J. (2012). Basic opioid pharmacology: An update. Br J Pain 6, 11–16.
    1. Poulsen, J.L. , Brock, C. , Olesen, A.E. , Nilsson, M. , Drewes, A.M. (2015). Evolving paradigms in the treatment of opioid‐induced bowel dysfunction. Therap Adv Gastroenterol 8, 360–372.
    1. Reguly, P. , Dubois, S. , Bédard, M. (2014). Examining the impact of opioid analgesics on crash responsibility in truck drivers involved in fatal crashes. Forensic Sci Int 234, 154–161.
    1. Ripamonti, C.I. , Santini, D. , Maranzano, E. , Berti, M. , Roila, F. (2012). Management of cancer pain: ESMO clinical guidelines. Ann Oncol 23 (Suppl 7), vii39–vii154.
    1. Sabatowski, R. , Schwalen, S. , Rettig, K. , Herberg, K.W. , Kasper, S.M. , Radbruch, L. (2003). Driving ability under long‐term treatment with transdermal fentanyl. J Pain Symptom Manage 25, 38–47.
    1. Sabatowski, R. , Scharnagel, R. , Gyllensvärd, A. , Steigerwald, I. (2014). Driving ability in patients with severe chronic low back or osteoarthritis knee pain on stable treatment with tapentadol prolonged release: A multicenter, open‐label, phase 3b trial. Pain Ther 3, 17–29.
    1. Simpson, K. , Leyendecker, P. , Hopp, M. , Müller‐Lissner, S. , Löwenstein, O. , De Andrés, J. , Troy Ferrarons, J. , Bosse, B. , Krain, B. , Nichols, T. , Kremers, W. , Reimer, K. (2008). Fixed‐ratio combination oxycodone/naloxone compared with oxycodone alone for the relief of opioid‐induced constipation in moderate‐to‐severe noncancer pain. Curr Med Res Opin 24, 3503–3512.
    1. de Stoutz, N.D. , Bruera, E. , Suarez‐Almazor, M. (1995). Opioid rotation for toxicity reduction in terminal cancer patients. J Pain Symptom Manage 10, 378–384.
    1. Tawfic, Q.A. , Bellingham, G. (2015). Post‐operative management in patients with chronic kidney disease. J Anaesthesiol Clin Pharmacol 31, 6–13.
    1. Tegeder, I. , Lötsch, J. , Geisslinger, G. (1999). Pharmacokinetics of opioids in liver disease. Clin Pharmacokinet 37, 17–40.
    1. Tuteja, A.K. , Biskupiak, J. , Stoddard, G.J. , Lipman, A.G. (2010). Opioid‐induced bowel disorders and narcotic bowel syndrome in patients with chronic non‐cancer pain. Neurogastroenterol Motil 22, 424–430.
    1. Vella‐Brincat, J. , Macleod, A.D. (2007). Adverse effects of opioids on the central nervous systems of palliative care patients. J Pain Palliat Care Pharmacother 21, 15–25.
    1. Webster, L.R. , Fine, P.G. (2012). Review and critique of opioid rotation practices and associated risks of toxicity. Pain Med 13, 562–570.
    1. Webster, L. , Dhar, S. , Eldon, M. , Masuoka, L. , Lappalainen, J. , Sostek, M. (2013). A phase 2, double‐blind, randomized, placebo‐controlled, dose‐escalation study to evaluate the efficacy, safety, and tolerability of naloxegol in patients with opioid‐induced constipation. Pain 154, 1542–1550.
    1. West, C. , Usher, K. , Foster, K. , Stewart, L. (2012). Chronic pain and the family: the experience of the partners of people living with chronic pain. J Clin Nurs 21, 3352–3360.
    1. Wilson, F.A. , Stimpson, J.P. , Pagán, J.A. (2014). Fatal crashes from drivers testing positive from drugs in the U.S., 1993–2010. Public Health Rep 129, 342–350.
    1. Wu, S.M. , Compton, P. , Bolus, R. , Schieffer, B. , Pham, Q. , Baria, A. , Van Vort, W. , Davis, F. , Shekelle, P. , Naliboff, B.D. (2006). The addiction behaviors checklist: Validation of a new clinician‐based measure of inappropriate opioid use in chronic pain. J Pain Symptom Manage 32, 342–351.
    1. Xu, S. , Etropolski, M. , Upmalis, D. , Okamoto, A. , Lin, R. , Nandy, P. (2012). Pharmacokinetic and pharmacodynamics modeling of opioid‐induced gastrointestinal side effects in patients receiving tapentadol IR and oxycodone IR. Pharm Res 29, 2555–2564.
    1. Council of Europe (CoE) (2003). Recommendations Rec (2003) 24 of the Committee of Ministers to member states on the organisation of palliative care. Adopted by the Committee of Ministers on 12 November 2003 at the 860th meeting of the Ministers’ Deputies. Strasbourg, France. (accessed 16 March 2016).
    1. DrugBank . Drug & Target Database (Version 4.3) (2015). (accessed 16 March 2016).
    1. . (2013). Drug Safety Update – Metoclopramide: risk of neurological adverse effects. (accessed 16 March 2016).
    1. . (2014). Drug Safety Update – Domperidone: risk of cardiac side effects. domperidone‐risks‐of‐cardiac‐side‐effects (accessed 16 March 2016).
    1. International Association for the Study of Pain (IASP) (2012). IASP Taxonomy. (accessed 16 March 2016).
    1. International Association for the Study of Pain (IASP) (2015). Pain: Clinical Updates. Volume 23, Issue 6 (November). (accessed 16 March 2016).
    1. The European Pain Federation (EFIC) (2013a). APPEAL (Advancing Provision of Pain Education and Learning) study. (accessed 16 March 2016).
    1. The European Pain Federation (EFIC) (2013b). The Pain Management Core Curriculum for European Medical Schools – Version July 2013. (accessed 16 March 2016).
    1. International Narcotics Control Board (INCB) (2016). Availability of narcotic drugs for medical use/availability of opioids for pain management 2010 – 2012. (accessed 31 August 2016)
    1. World Health Organization (WHO) . (2011). Achieving a balance in national policies on controlled substances – guidance for availability and accessibility of controlled medicines. Geneva, Switzerland. (accessed 16 March 2016).

Source: PubMed

스폰서 및 공동 작업자

건강 상태

약물 개입

3
구독하다