__________________ Effective Management of Acute and Chronic Pain with Opioid Analgesics, 2nd Edition
The choice of medication may be driven by patient risk factors for drug-related adverse effects (e.g., NSAIDs increase the rate of gastrointestinal, renal, and cardiovascular events). If acetaminophen or NSAIDs are contraindicated or have not sufficiently eased the patient’s pain or improved function despite maximal or combination therapy, other drug classes (e.g., opioids) are sometimes used. Nonopioid analgesics are not without risk, particularly in older patients. Potential adverse effects of NSAIDs include gastrointestinal problems (e.g., stomach upset, ulcers, perforation, bleeding, liver dysfunction), bleeding (i.e., antiplatelet effects), kidney dysfunction, hypersensitivity reactions, and cardiovascular concerns, particularly in the elderly. The threshold dose for acetaminophen liver toxicity has not been established; however, the FDA recommends that the total adult daily dose not exceed 4,000 mg in patients without liver disease (with a lower ceiling for older adults with certain conditions). The FDA currently sets a maximum limit of 325 mg of acetaminophen in prescription combination products (e.g., hydrocodone and acetaminophen) in an attempt to limit liver damage and other potential ill effects of these products. TOPICAL AGENTS Topical capsaicin and salicylates can both be effective for short term cutaneous pain relief and generally have fewer side effects than oral analgesics, but their long-term efficacy is not well studied. Topical NSAIDs and lidocaine may also be effective for short-term relief of superficial pain with minimal side effects. Topical agents can be simple and effective for reducing pain associated with wound dressing changes, debridement of leg ulcers, and other sources of superficial pain. ANTICONVULSANTS Anticonvulsants, such as gabapentin, pregabalin, oxcarbazepine, and carbamazepine, are often prescribed for chronic neuropathic pain (e.g., post-herpetic neuralgia and diabetic neuropathy), although evidence for efficacy in acute pain conditions is weak [47]. A 2017 trial, for example, randomized 209 patients with sciatica pain to pregabalin 150 mg/day titrated to a maximum of 600 mg/day versus placebo for 8 weeks [48]. At 8 weeks there was no significant difference in pain between groups. OPIOIDS FOR ACUTE PAIN: USE CAUTION Opioids are commonly prescribed for pain, with nearly two- thirds (64%) of the public reporting being prescribed an opioid for pain at some point in their lives [49]. However, this approach is not as safe and effective as once thought, and high-dose prescriptions or prolonged use not only increase the risk of misuse, addiction, or overdose, they may actually increase pain and pain sensitivity [50][51]. Evidence suggests that opioids may not be more effective for moderate-to-severe acute pain than nonopioid pain regimens [52][53].
Physical dependence can readily occur after use of opioids at a sufficient dose for just a few days. In addition, side effects of opioid use can include constipation, confusion/gait instability, respiratory depression, pruritus, erectile dysfunction, and fractures, all of which may be more problematic in older patients and occur at higher rates than with nonopioid analgesics. In a retrospective study of 12,840 elderly patients with arthritis, opioid use was associated with an increased risk relative to nonopioids for cardiovascular events, fracture, events requiring hospitalization, and all-cause mortality [54]. The risk of prolonged opioid use is particularly high after arthroscopic joint procedures. In a 2019 case-control study of 104,154 opioid-naïve adults, 8,686 (8.3%) developed new prolonged opioid use (continued opioid use between 91 and 180 days after shoulder arthroscopy) [55]. Subgroups at higher risk for long-term use included women, those with a history of alcohol use disorder, those with a mood disorder, and those with an anxiety disorder. OPIOID CHOICES FOR ACUTE PAIN If an opioid is deemed necessary to treat moderate-to-severe acute pain, the following general principles are recommended when starting an opioid: • Avoid extended-release and long-acting opioids such as methadone, fentanyl patches, and ER/ LA versions of opioids such as oxycodone or oxymorphone. • Avoid co-prescribing opioids with other drugs known to depress central nervous system function (e.g., benzodiazepines). • Limit the dose and quantity of opioids to address the expected duration and severity of pain (usually less than 7 days). • Combine opioids with other treatments (e.g.,
nonpharmacologic options such as exercise or cognitive behavioral therapy, NSAIDs, or acetaminophen).
• Closely monitor patients with impaired hepatic or kidney function if they are prescribed opioids, and adjust the dose or duration accordingly. Immediate-release agents are strongly preferred because of the higher risk of overdose associated with ER/LA agents. A cohort study of 840,000 opioid-naïve patients over a 10-year span found that unintentional overdose was 5 times more likely in patients prescribed ER/LA agents compared to immediate- release opioids [56].
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MDUT1125
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