Optimal Opioid Therapy and Redefining Cancer-Related Pain

Charles E. Argoff, MD


July 27, 2012

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Hi, my name is Dr. Charles Argoff. I am Professor of Neurology at Albany Medical College and Director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York. Today I want to tell you about several important issues discussed at the annual meeting of the American Pain Society (APS), held in mid-May of this year in Honolulu, Hawaii.

One of the most critical issues currently being examined in pain management is the proper use of opioid therapy. What is the best use of chronic opioid therapy in individuals who do not have cancer-related pain? During the APS, we had several lively discussions about the effective use of opioids and chronic opioid therapy for individuals who have chronic noncancer pain. One session looked at the effect of the Washington State guidelines on chronic opioid therapy and pain management in general.[1] In another important session,[2] during the ethics special interest group, Dr. Mark Sullivan from the University of Washington and I discussed the effects of the Washington State law that, in many ways, limits the use of opioids for patients with chronic noncancer pain.

I want to summarize what was expressed and highlight some points [we need to carefully consider]. First, no study has suggested that all individuals who are given opioids for chronic pain management purposes benefit from opioids. There also has never been a study that indicates that gabapentin, nonsteroidal anti-inflammatory drugs, or antidepressants used for pain relief have benefit for everyone who receives them. If we are honest about the appropriate positioning of chronic opioid therapy for non-cancer-related pain, several points that came through in sessions presented at the APS -- and that what we could agree upon going forward -- were that we want to maximize safety. The Washington State law, for example, emphasizes that safe use is paramount, and that prescribing more than 120 mg of morphine or its equivalent on a daily basis, higher doses in particular, are certainly more dangerous for the overall population and are really appropriate for relatively few people.

One important point that was made repeatedly by those supporting the Washington State guidelines was about [avoiding] high doses. At the same time, we cannot throw the baby out with the bath water, meaning that we cannot say that chronic opioid therapy is not useful for everyone with chronic pain. We also cannot say that we can predict with absolute certainty the best way to treat someone who has chronic pain. That point was also accepted -- that a subset of individuals with chronic noncancer pain exists that is appropriately treated with chronic opioid therapy.

We all agreed that this requires proper training, proper monitoring of individuals, and the right context with emphasis not only on pain relief but on functional restoration for that person. That is where an interesting discussion came about with Dr. Mark Sullivan. The State of Washington established a law that essentially limits the dosing -- and to a certain extent the prescribing -- of chronic opioid therapy for non-cancer-related pain. However, the state did not implement funding for the kind of functional restoration, pain rehabilitation, and other pain treatments that may help people who either do not respond to opioid therapy or need therapies in addition to chronic opioids to maximize their benefit. What it came down to is that we are in a predicament. We can agree that chronic opioid therapy can be effective for non-cancer-related pain for some, perhaps 20% or 30% at most in the long term. We do not have 5- and 10-year data to support that, but we do have several-year data and certain studies for up to 3 years of following people for whom a more multimodal approach may be helpful. The State of Washington did not fund a multimodal approach in place of restrictions on opioid therapy. Fortunately, we all agreed ideally and practically that, if we are going to offer patients chronic opioid therapy or consider it, certainly we must do so in the context of a true multidisciplinary, multimodal approach so that we can maximize safety, optimize outcomes, and help patients, knowing that at the end of the day, not everyone will benefit from opioid therapy, and therefore it would not be continued for those for whom it is not beneficial.

Finally, another issue that came up repeatedly is that of cancer- vs non-cancer-related pain. I think we have a handle on [what we mean by] noncancer-related pain. But what [do we mean by] cancer-related pain? This is a subject that is not very clear anymore. It is now well documented that in certain cancer pain studies, individuals who were included did not have active cancer. They may have had pain related to a cancer that had been in remission for 10 years, and yet they were included in those studies. We need guidance and a clearer definition of what we mean when we talk about cancer pain. Many people who are included in the cancer pain category have not had an active cancer for a decade or more. When a patient has a remote history of cancer, it would not seem logical or rational to include them as "cancer pain individuals."

Thank you for your attention. I am Dr. Charles Argoff.


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