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References and Resources: Pain and Opioid Therapy Collection

Compiled by Alexander DeLuca: 1998 - 2005.   Originally posted: 2002-12-12;  Most Recently Revised: 2006-01-10 - New!

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Principles of Opioid Management of Pain - Joel Hochman and members of NFTP and PRN listServ; Summer 2006
--

The Project for Pain and Chemical Dependency:  
'Defining What is Right, Not What is Wrong'
 
Comment (DeLuca):
A consensus document defining medically correct, ethical, patient-centric, respectful opioid treatment for pain.
 

Unlike almost every other such effort  promulgated by pain societies or Fed. agencies, Principles does not encourage physicians take on a law enforcement role, and does not discriminate against high-dose patients or non-medical drug users in pain.
   
 
See also:
'High Dosage' Opioid Management -
Hochman; Practical Pain Management; 2005
 
Chronic Pain:
I - A New Disease?  ;  II - The Case for Opiates -
Daniel Brookoff; Hospital Practice; 2000
 
White Paper on Opioids and Pain: A Pan-European Challenge
- compiled by OPEN Minds; 2005
 
 
The Big Chill - Inserting the DEA into End-of-Life Care -
Timothy E. Quill and Diane E. Meier; New England Journal of Medicine; 345(1); 1-3; 2006-01-06
--
"A finding in favor of the Justice Dept  [in Gonzalez v. Oregon] would not only nullify the Death with Dignity Act, permitting the DEA to penalize physicians for providing medications to hasten the deaths of terminally ill patients, but also have a chilling effect on physicians' willingness to treat patients' terminal symptoms."
 
See also:
Let's Get Serious About Chronic Pain (PDF) - Jane Brody; New York Times; 2006-01-10
 

 
Universal Precautions in Pain Medicine: A Rational Approach to the Treatment of Chronic Pain by Gourlay et al.; Pain Medicine; March 2005
--
"All patients [need to be assessed] in a biopsychosocial model, including past and present aberrant behaviors... and by applying careful and reasonably set limits in the clinician-patient relationship, it is possible to triage chronic pain patients into three categories according to risk.

Comment:
Peer-reviewed journal article proposing 'universal precautions' be applied to pain patients as potential addicts - sort of like they had a fatal, highly infectious disease (which neither pain nor addiction are). This is NOT a prescription for stigma-reduction, BTW.
 
It's official: Pain Medicine and Addiction Medicine have 'Jumped the Shark.'
 

 
Opioid Rotation in Patients with Cancer Pain - Bruera et al.; Cancer; 78(4); 852-857;  1996 -- "The dose ratio between morphine and hydromorphone was 5.33... However, the hydromorphone / methadone ratio was found to be 5 to10 times higher than expected [given methadone's equipotence with morphine]."

See also:
Opiate Rotation, Incomplete Cross-Tolerance, and Hyperalgesic Metabolites DeLuca; 2001
 
Psychostimulants as Adjuvant Analgesics -
Bruera and Watanabe; J Pain Symptom Manage.; 1994
 
High-Dose Ketamine in Neuropathic Pain -
Tarumi et al.; J Pain Symptom Manage.; 2000
 

 
High-Dose Ketamine in Neuropathic Pain - Tarumi, Y.; Watanabe, S.; Bruera, E.; Ishitani, K.; Journal of Pain and Symptom Management; 19(6); 2000. Posted: 2005-12-04 -- "Neuronal hyperactivity is at least partially mediated by N-methyl-D-aspartate (NMDA) receptors and agonists. Clinical evidence has reported that NMDA receptor antagonists reduce pain caused by nerve injury. Ketamine is one of the commercially available NMDA antagonists. We report a case in which ketamine was successfully used to treat severe neuropathic pain."
 

 
Opioids in Pain Management - Henry McQuay; Lancet; 353; 2229-2232;1999-06-26 -- "Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing... The restriction of opioid availability to protect society and the individual continues in many countries. In this review I focus on chronic and cancer pain, but many of the principles apply in acute pain. The justification for this focus is that patients with chronic pain may suffer longer and unnecessarily if we prescribe and legislate badly."
 

Tutorial: The Role of Opioids in Cancer Pain Management - M. Fukshansky, et al.; Pain Practice, 5(1), 2005

Comment (DeLuca):
This medical journal tutorial includes a brief overview of pain syndromes, and reviews the basics of opioid therapy, opioid pharmacology, opioid rotation, the properties of the individual opioids, and the management of common side effects of opioids.
 
See also:
Chronic Pain II – Case for Opiates; Daniel Brookoff; Hospital Practice; 35(9); 2000

 

Emergency Withdrawal: Pain Meds in the Wake of Katrina - American Pain Foundation Alert; 2005-09-04

Comment:
The American Pain Foundation offers this brief, peer-reviewed and credible  information to help individuals understand withdrawal symptoms, warnings, and tips about how to taper medication to lessen or avoid withdrawal.
 

White Paper on Opioids and Pain: A Pan-European Challenge Compiled by OPEN Minds; 2005-06 -- "The reputation of opioids has been damaged by a singular 'war on drugs' emphasis aimed only at their potential for abuse... [What] is required... is a straightforward process of updating the numerous rules and regulations that are identified in this White Paper."
 

 
Medical Marijuana, Federalism, and the Supreme Court  by Gostin; JAMA; 2005; 294(7); 842-844 -- "[M]arijuana may offer respite for some patients—a position supported by patient experiences and physician opinions. The "drug war" metaphor does not justify an ideology that removes hope from patients when they are most vulnerable and in need."
 

See also:
War on Pain Sufferers #3: - Medical MJ

 

 
Characterizations of Long-term Oxycodone / Acetaminophen Prescriptions in Veterans by J.A. Hermos et al.; Arch. Internal Med.; 2004

Comment:
They went looking for abuse and escalating doses, and found mostly stable patients.
Unfortunately, the authors fail to measure the clinical adequacy or inadequacy of the opioid therapy provided. The average VA dose for the "long term management of chronic pain" is apparently four Vicodin daily - a shockingly LOW dose for anything other than the mildest chronic pain.
 

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Methadone for Pain States by Toombs & Kraal; Amer.Fam.Physician; 4/1/2005 -- "Methadone's unique pharmacokinetics and pharmacodynamics make it a valuable option in the management of... chronic pain, including neuropathic pain states. It may be an appropriate replacement for [other] opioids when side effects have limited further dosage escalation."

Comment:
Brief but pretty good review of the pharmacology of methadone and principles of it's use for the treatment of chronic pain.
 

"High Dosage" Opioid Management - Considerations in Treating Intractable Pain by J.S. Hochman, MD, Executive Director NFTP; Practical Pain Management; March 2005 -- "When titrated carefully to effectiveness, patients achieve dramatic improvement in pain levels and function, with no evidence of adverse effects, medical complications or addiction... Addiction is non-existent in our most recent series of 204 patients followed for four years."
 

The Challenge of Prescription Drug Misuse: A Review and Commentary by William Hurwitz; Pain Medicine; 6(2); March '05 --  "How can there be a balanced policy without a scale to measure all the relevant outcomes?"
 

Opioid Use in Orthopedic Spine Clinic Mahowald et al.; Arthritis & Rheum.; Jan. 2005 -- This study provides evidence to support [opioid therapy by] docs treating chronic musculoskeletal diseases [and protect them] from regulatory agencies. [It]will benefit patients by [easing access] to these effective, safe medications.

 Comment:
Wow; this could be huge.
 

A New Set of Knees Comes at a Price: A Whole Lot of Pain by Jane Brody; New York Times; 2/8/2005 -- "I learned much later that I could have been prescribed a much higher dose of narcotics with no ill effect and much better pain control. No doctor I reported to, however, including the surgeon, even considered that."
 
 
Opioid Rotation in Patients with Cancer Pain - Bruera et al.; Cancer; 78(4); 852-857;  1996
--
"The dose ratio between morphine and hydromorphone was 5.33... However, the hydromorphone / methadone ratio was found to be 5 to10 times higher than expected [given methadone's equipotence with morphine]."
 
See also:
Opiate Rotation, Incomplete Cross-Tolerance, and Hyperalgesic Metabolites
DeLuca; 2001
 
Psychostimulants as Adjuvant Analgesics -
Bruera and Watanabe; J Pain Symptom Manage.; 1994
 
New! - High-Dose Ketamine in Neuropathic Pain -
Tarumi et al.; J Pain Symptom Manage.; 2000
 

 
High-Dose Ketamine in Neuropathic Pain -
Tarumi, Y.; Watanabe, S.; Bruera, E.; Ishitani, K.; Journal of Pain and Symptom Management; 19(6); 2000. Posted: 2005-12-04 -- "Neuronal hyperactivity is at least partially mediated by N-methyl-D-aspartate (NMDA) receptors and agonists. Clinical evidence has reported that NMDA receptor antagonists reduce pain caused by nerve injury. Ketamine is one of the commercially available NMDA antagonists. We report a case in which ketamine was successfully used to treat severe neuropathic pain."
 

 
Opioids in Pain Management - Henry McQuay; Lancet; 353; 2229-2232;1999-06-26 -- "Opioids are our most powerful analgesics, but politics, prejudice, and our continuing ignorance still impede optimum prescribing... The restriction of opioid availability to protect society and the individual continues in many countries. In this review I focus on chronic and cancer pain, but many of the principles apply in acute pain. The justification for this focus is that patients with chronic pain may suffer longer and unnecessarily if we prescribe and legislate badly."
 

Chronic Pain: Part 1. A New Disease?  Part 2. The Case for Opiates  by Daniel Brookoff; Hospital Practice; 2000.  --  "If a patient's physical pain has prevented him or her from living life fully, using a medication that allows a return to normal activities cannot be called drug abuse." --

Compare and contrast to the article by Ballantyne  (directly below). Brookoff is accurate, thorough, and lacks the creepy, vapid feeling of Ballantyne's work. This is a far better Review, IMO.     ..alex...
 

Opioid Therapy for Chronic Pain by Ballantyne & Mao; NEJM; 11/13/2003. I disagree with many of the conclusions and implications that arise from this review, for example, the concept of a "ceiling" dose limit. But this is an important article even though I find it perpetuates traditional, wrongheaded, WOD thinking.     ..alex...
 

Lost Productive Time & Cost Due to Common Pain Conditions in the US by Walter Stewart, et. al., JAMA, 11/12/2003. "Conclusion: Pain is inordinately common and disabling... Most pain-related lost productive time occurs... as reduced performance."
 

Race, Ethnicity, & Pain Treatment - by Vence Bonham; J. Law, Med. & Ethics, 2001. "Racial and ethnic minorities are at higher risk for the ineffective treatment of pain. While others have investigated racial and ethnic disparities in access to health services generally, Bonham presents the first comprehensive review of the literature on racial and ethnic disparities in the treatment of pain."
 

Pain Management and Provider Liability: No More Excuses - by Barry Furrow; J. Law, Med. & Ethics, 2001. "Pain is undertreated in the American health-care system at all levels: physician offices, hospitals, longterm facilities. The result is needless suffering for patients, complications that cause further injury or death, and the added costs in treatment overall. ... Excuses for shortcomings are simply not acceptable any longer."
 

Interpretation of "Aberrant" Drug-Related Behaviors [PDF] - by Frank B. Fisher, M.D., J.Amer.Physicians & Surg. 2004. -- Excellent examination, by a guy who has really been  there, of the crucial "Doctors Dilemma"- the impossibility of distinguishing the “deserving” chronic pain patient from the presumably undeserving drug addict.   ..alex...
 

Mixed Message on Prescription Drug Abuse. by Brian Vastag; JAMA, 2001.-- "The most egregious underprescribing occurred with idiopathic back pain, the most common kind. While the expert panel recommended that virtually all patients with such pain-and who do not respond to other treatments-be given an opioid analgesic, only 20% of physicians said they would actually write that prescription. "
 

Pain Patients and Docs Now Causalities of War on Drugs - Yearbook of Experts, Authorities and Spokespersons, June 30, 2004. -- "'The war on drugs has turned into a war on doctors and the legal drugs they prescribe and on the suffering patients who need the drugs to attempt anything approaching a normal life," said Kathryn Serkes, of the AAPS... Assistant U.S. Attorney Gene Rossi declared to a reporter that 'our office will try our best to root out [certain doctors] like the Taliban. Stay tuned.'"
 

Pain Without Treatment,  Wrong Without Remedy  by William Hurwitz, M.D., 1992. -- "This [paper] argues that pain patients are protected as persons with disabilities entitled to appropriate medical treatment and that the regulatory scheme, through its disparate impact on their access to such treatment, violates the law."
 
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Amphetamines and Analgesia - I.D.M.U.; British National Formulary 35 (March 1998) p186
 
The Role of Psychostimulants in Patients with Cancer Pain by Bruera; 1995.
 
Potentiation of opioid analgesia by psychostimulant drugs: a review - by Dalal; Pain Symptom Manage 1998 Oct; 16(4): 245-53 (Abstract)
 
Chronic Pain In America: Roadblocks To Relief by Rovine; 1999; From the American Pain Society
 
Defining Key Terms in Pain Management - Purdue Pharma
 

Chronic Pain: Treatment Barriers and Strategies for Clinical Practice by Glajchen; 2001; Journal of Amer. Board of Family Practice, 14(3):178-183. (Abstract & Introduction)
 

Recognizing preventing and medication diversion. by Cole; 2001; Fam.Pract.Manag., Vol. 8, No. 2, pp 37-41
 
How Pain is Under Treated in the US by Skip Baker; From the American Society for Action on Pain
 
Management of Chronic Non-Cancer Pain: A Guide to Appropriate Use of Opioids by Schneider; 1998;  Journal of  Care Management
 
Opiate Rotation and Hyperalgesic Metabolites by DeLuca, 2001.
 
Opioid Therapy for Chronic Nonmalignant Pain: Clinicians' Perspective by Russell K. Portenoy. Journal of Law, Medicine & Ethics, 24(4): 296-309; 1996.
 
The OxyContin Controversy (Common Sense for Drug Policy ) - circa June, 2001.
 
New form of OxyContin would thwart abusers by Rubin, USA Today; 8/13/2001.
 
The truth about oxycontin from a medical point of view by DeLuca; 8/8/2001.
 
Pain Specialists and Addiction Medicine Specialists Unite to Address Critical Issues - by Portenoy; APS Bull.;    9(2); April 1999.
 
When Not Treating Pain Equals Abuse - With a hefty verdict, California jury sends hospitals a message about relieving patients agony. by Greene; 2001; Health and Hospital News, October 2001, pp 34.  Ms. Lee, president of the Compassion In Dying Federation is quoted: "The entire medical community is now on notice about the seriousness of the undertreatment of pain, [t]his is medical education by jury trial."
 
 

Dr. DeLuca's Addiction, Pain, and Public Health Website

Alexander DeLuca, M.D., FASAM

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Originally posted:  2002-12-12

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