How Much Pain Medication Should I Give?

Blaine P. Carmichael, MPAS, PA-C

Disclosures

April 17, 2001

Question

My patients seem to always want more pain medicine than I am comfortable giving them. I am concerned that if I give them more pain medication that this will lead to addiction. How can I prevent addiction, relieve patients' pain, and minimize drug-seeking compulsions?

Amy Lupton, MMS, PA-C

Response from Blaine P. Carmichael, MPAS, PA-C

The most common cause of escalating pain complaints is worsening disease, not tolerance to pain medications. Pseudo addiction (drug-seeking behavior) is caused by inadequate analgesic medication prescribing. In pseudo addiction, the drug-seeking behavior stops when adequate medication dosages are given. In comparison, in true addiction, drug-seeking behavior continues to escalate.

The difference between tolerance, physical dependence, and addiction is frequently misunderstood. The belief that the use of opioids for pain relief causes addiction is a common clinical misconception that is a significant barrier to good pain management. It is useful to divide "addiction" concerns into 4 categories to improve clarity of understanding.

Tolerance. Tolerance is defined as a need for a larger dose of a medication to maintain the original effect. It is important to remember that a need for increased doses may also represent a change in the cause of pain (new etiology, advancement of original process, etc.) requiring reassessment. This is often the reason for a need for increased doses in the terminally ill. When tolerance does occur, it is easily managed by increasing the dose -- tolerance to analgesic effect tends to parallel tolerance to toxic effects.

Physical dependence. Physical dependence is defined as development of withdrawal symptoms when opioids are discontinued abruptly or when opioid antagonists are administered. Like tolerance, this is a normal physiologic response (expected after 2-4 weeks of regular use). Opioids are not unique in this regard. Many other medications such as beta-blockers, alpha-2 agonists, and selective serotonin reuptake inhibitors (SSRIs) also cause withdrawal symptoms. In cases in which pain decreases in the course of an illness (as may happen after radiation to bone metastases or steroid treatment for increased intracranial pressure), most patients taper their narcotic use over a short period without difficulty. Therefore, this is very seldom a clinical problem. I recommend that the opioid be reduced by 50% every 2 or 3 days.

Psychological dependence. Psychological dependence is defined as a pattern of compulsive drug use characterized by the use of an opioid for effects other than pain relief and continued use despite harm. Terminally ill patients virtually never become psychologically dependent in any negative sense to properly administered narcotics. Patients and their families should be counseled about the rarity of addiction when opioids are prescribed for management of pain under medical supervision.

Pseudo addiction. The pseudo addiction syndrome is begins with inadequate pain management. Patients develop feelings of anger and isolation, which lead to acting-out behavior. The clinician may initially experience frustration at not controlling the patient's complaint of pain, along with fears of inducing tolerance and dependence. Over time, clinicians may seek to avoid contact with the patient as a means of reducing the source of conflict. Both cycles continually interact until a crisis based on mistrust results.[1] When pseudo addiction is recognized as a true iatrogenic syndrome, the way in which patients receive pain treatment will hopefully improve.

Inadequate pain management leading to pseudo addiction has these features:

  • analgesic narcotics prescribed as needed, rather than scheduled around the clock

  • dosing intervals that are greater than the duration of action of a given analgesic

  • the use of insufficiently effective analgesics or of inadequate doses

Underlying causes of inadequate pain management include inadequate education about pain management, excessive fear of addiction, and underutilization of existing pain management techniques.

Preventing pseudo addiction includes trusting the patient's report of pain. Remember that pain is a subjective phenomenon; use opioids appropriately based on the patient's report of pain. Important components of appropriate opioid use include scheduled rather than dosing as needed and providing rescue medication for breakthrough pain.

Response from Blaine P. Carmichael, MPAS, PA-C

In summary, the physician assistant must provide reassurance that aggressive treatment will be given to every type of pain that the patient is experiencing. Four general principles are used in prescribing and dosing analgesic medications:

  1. The choice of analgesic drug should be based on the type of pain.

  2. Patients with chronic or frequently recurring pain should receive medications around the clock according to the recommended dosing schedules. This allows attainment of a steady state of medication, which minimizes side effects and avoids periods of subtherapeutic analgesia.

  3. Episodic or breakthrough pain should be anticipated and treated with as-needed pain relief in addition to the regularly scheduled analgesics. When opioids are used, the available daily breakthrough dosage should be equal to the regularly scheduled analgesic dosage. For example, if a patient were receiving 30 mg of sustained-release morphine (MS-Contin) every 12 hours, the breakthrough morphine dosage would be 10 mg administered every 4 hours. (Both approaches result in a dosage of 60 mg per 24 hours.) If large amounts of breakthrough medications are required, consideration should be given to raising the dosage of the regularly scheduled analgesic. In general, only "as-needed prescribing" should be avoided.

    Tylox (oxycodone and acetaminophen), a schedule II narcotic, is a good choice for breakthrough pain rescue. For less severe types of chronic pain, Ultram (tramadol), a narcotic receptor agonist that is not DEA-controlled, is very effective. Ultram is best used on a regular schedule. I start at 50 mg q8h and move up in a stepwise fashion to 100 mg po q6h. Using tramadol on an as-needed basis should be avoided as it has a 2-hour onset of action. Myofascial pain can often be reduced with a nonnarcotic analgesic and muscle relaxant such as Parafon Forte DSC (chlorzoxazone).

  4. Medication dosages should be titrated promptly to achieve effective pain control. For most medications, dosage adjustments can be made every 24-48 hours. Dosages of morphine and other strong opioids can be safely increased by 50% every 24 hours until a satisfactory response is obtained. Conversely, opioid dosages can be decreased by 50% to 75% every 24 hours without causing withdrawal symptoms.

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