Case Scenario

One of my patients was diagnosed with a rare form of cancer three years ago. The cancer is now in remission, but her long-range prognosis is not good. Before the cancer diagnosis, she had been receiving opiates for a pain syndrome. Following cancer surgery, she took oxycodone in a steady dosage of 40 mg daily and was seen by a rheumatologist, a surgeon, an oncologist, and me. Several months ago, the patient received a hip replacement and had a lot of postsurgical pain that required a higher dosage of narcotics—specifically, 80 mg of oxycodone daily.

I imagine that she now must be past the most painful aspects of the joint replacement, but I can't convince her to go back to her earlier 40-mg daily dosage of oxycodone. This patient is seriously ill with several painful, concomitant medical conditions that are unrelated to her joint problems or the cancer, and she is miserable in many aspects of her life. Because of her situation, I feel reluctant to force her back to a 40-mg dosage. On the other hand, if her cancer does not remain in remission, I'm afraid that I'll be escalating her dosage with each exacerbation of pain. Should I let her decide how much pain medication she needs, given the many reasons she has for pain, and escalate accordingly? Is there a way of reducing a dosage after a painful exacerbation, and should I insist on it? Would a contract be useful in this volatile setting?

Commentary

Over the past decade, the promotion of narcotics for control of malignant and non-malignant pain has been advocated by specialists in the pain community.¹ While most physicians accept the use of aggressive narcotic analgesia in patients with cancer-related pain, the use of opioids in chronic, nonterminal conditions remains highly controversial.

What is the evidence that narcotic analgesia is efficacious in relieving chronic nonmalignant pain? Most of the literature on opioid therapy has relied on surveys and uncontrolled case series.² Clinical evidence suggests that some patients with chronic pain can achieve satisfactory analgesia for years without an escalation in dosage. However, there remains little discussion about how to determine patients who are good candidates for this practice and patients who are not.

Who should not be prescribed narcotics for chronic pain? In a poignant article recently published in The New York Times, the author states, “…the reassessment of narcotic risk comes at a time of skyrocketing rates of misuse and abuse of such drugs.”³ Advocates prescribe chronic narcotic therapy for low back pain without objective pathology, and some prescribe it for such nebulous conditions as fibromyalgia,⁴ presumably based on an assumption that subjective complaints justify long-term narcotic usage. A literature search reveals no articles to support the use of narcotics for fibromyalgia pain. At the same time, overly optimistic statements about the minute incidence of narcotic dependence and addiction must be reexamined.

The rate of iatrogenic addiction to narcotics has been studied incompletely. Previously, advocates of narcotics for nonmalignant pain have cited studies showing a low risk of addiction. However, one of these studies failed to follow patients from inpatient to outpatient settings, so the incidence actually is unknown; in addition, other studies were mischaracterized or misquoted.³ Indeed, in a study of patients using methadone for treatment of addiction problems, a high incidence of chronic, dysfunctional pain problems occurred in both inpatient and chronic-maintenance methadone patients.⁵ In the past, manufacturers of long-acting narcotics have marketed these products aggressively without underscoring their addictive risk.

Before considering or continuing chronic narcotic therapy for nonmalignant pain, several questions should be considered.

Was the patient adequately screened for psychopathology before initiating narcotics? Most physicians would agree that narcotics are inappropriate for patients with chemical dependency, significant character pathology, and psychiatric illness.

Does the prescription of narcotics in patients with an ill-defined pain syndrome (such as fibromyalgia) legitimize their belief system as to their supposed pathophysiologic state? Many patients have a somatoform component in their presentation related to underlying “psychological confounders.”⁶ Prescribing narcotics may simply confirm in the patient's mind that the problem is somatic when it is not. This step exposes the patient to the risk of narcotics without addressing the underlying disorder, which is often depression.

Is the narcotic dosage beyond that which has been shown to produce significant results in other patients? The dosage of opioids in most studies was less than 180 mg of morphine or equivalent per day.⁷

Are the physician and patient comfortable with the long-term risks of opioid analgesia? Most physicians would be surprised to learn that studies of opioid efficacy have not evaluated patients beyond eight months of treatment.

Other questions to be considered are:

• Has the patient shown an improvement in functional skills (i.e., activities of daily living) while taking opiates?

• Does the narcotic prescription pose an impediment to vocational rehabilitation?

• Do legal risks associated with opioid use or altered mental status preclude a return to the work setting (e.g., operating machinery while taking a narcotic)?

• Is there a change in motivation associated with opioid use?

• Does narcotic analgesia result in reduced utilization of pain-related health resources?

• Are patients aware of the long-term hormonal changes, such as decreased cortisol, increased prolactin, and testosterone depletion?

• Were patients advised that there is overwhelming evidence that opioids alter innate as well as adaptive aspects of the immune system?

In general, most patients with chronic pain problems should not be prescribed narcotics for long-term use unless the patient has a clear understanding of the risks and side effects, and the underlying psychopathology has been addressed. Narcotic therapy may be continued on a long-term basis if there is no evidence of ill effect, if there is functional improvement in the patient, and if there is no evidence of dosage escalation or dependency issues. The physician must be sensitive to the effect of narcotics on the patient's sensorium and the possibility of impairment within the spheres of driving and employment.

The patient in this scenario has cancer in remission, had a recent total joint arthroplasty, was taking a moderate and steady dosage of 40 mg of oxycodone per day, and now requires 80 mg per day. The patient has a number of known-to-be-painful conditions, including malignancy, and has not had a persistent escalation of the drug dosage; instead, she had a single step up from 40 to 80 mg of oxycodone per day. In chronic cancer patients who are opiate-tolerant, doses of oxycodone of 20 to 45 mg orally every four hours may be required, and some patients require as much as 120 mg orally every four hours. In this context, this patient's opiate requirements are not exceedingly high. In addition, the ceiling dosage of oxycodone is less clearly defined than it is with drugs such as morphine or methadone.

Vocational and long-term side effects of opiate use seem to be less of a concern in a patient whose multiple medical problems imply a limited life span. In summary, if the patient is stable on 80 mg of oxycodone without undue side effects, the present management seems appropriate.

Although a pain contract has been advocated in the treatment of patients on chronic opiate therapy, it is not a substitute for careful screening for psychiatric comorbidities before initiating or escalating narcotic medications.