Opioids for Chronic Pain: Maximizing Benefits and Minimizing Risks

Daniel P. Alford, MD, MPH

General Internal Medicine
Department of Medicine
Boston University School of Medicine
Boston, Massachusetts

Opioid analgesics are increasingly being prescribed for the management of chronic pain despite incomplete evidence for long-term efficacy and the ongoing risk of abuse. Factors predictive of aberrant opioid-related behaviors include personal or family history of substance abuse and certain psychiatric pathologies. Unfortunately, some evidence suggests that these patients are also more sensitive to painful stimuli and may have pain that responds well to opioid treatment. Thus, when prescribing opioids, it is important to assess risks prior to prescribing any pain management plan, structure therapy based on potential problems, and monitor improvements and/or negative effects. Here Dr. Alford describes methods to define and assess patient outcomes that result from long-term opioid therapy, including the PEG scale (Pain intensity, interference with Enjoyment of life, and interference with General activity), patient agreements, and urine testing. Dr. Alford emphasizes that the clinical assessment is not final step in the process; rather appropriate interpretation of findings, communication with patients, and tailoring of the therapeutic plan are required.

References

1.    Starrels JL, Becker WC, Alford DP, et al. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med. 2010;152:712-720.
2.    Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113-130.
3.    Gilson AM, Ryan KM, Joranson DE, Dahl JL. A reassessment of trends in the medical use and abuse of opioid analgesics and implications for diversion control: 1997-2002. J Pain Symptom Manage. 2004;28:176-188.
4.    Krebs EE, Lorenz KA, Bair MJ, et al. Development and initial validation of the PEG, a three-item scale assessing pain intensity and interference. J Gen Intern Med. 2009;24:733-738.

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