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Concerns miss-concepts and Facts of Opioids (morphine derivatives)

Active Therapy for Pain

 Opioids are medications similar to narcotics, but are not made from opium. They are used as treatment to manage pain. The following information is intended to clarify the truth about Opioids and to dispel the most common 11 myths that have been created about opioids.

This is a general guide to clarify some of the issues related to pain management, and is not intended to replace or modify without medical supervision the recommendations of a specialized nurse or physician.

 Concern #1

Opioids reduce respiratory (breathing) functions, which makes them too dangerous to use.


If opioids are prescribed in the right doses, trouble with respiratory functions is rare (though it is the chief concern when taking opioids). The federal Agency for Health Care Policy and Research (AHCPR), in its recent Clinical Practice Guideline for cancer pain, has stated that “patients receiving long-term opioid therapy usually develop tolerance to the respiratory-depressant effects of these agents.” Experts have also suggested that pain and emotional stress themselves counteract the negative effects of the drug, making one’s breathing functions remain fairly normal. Studies of patients with advanced malignancies show that respiratory failure is not common or severe in those receiving high doses of morphine by mouth. Respiratory trouble due to opioid use occurs most often in elderly or debilitated patients, usually following large initial doses in patients not yet used to the medication, or when opioids are given along with other medications that also reduce normal breathing functions.


Concern #2

Opioid addiction can become a big problem.


For cancer patients and non-cancer patients, addiction risk appears to be low.For terminally ill patients, concerns about addiction are largely irrelevant and can interfere with proper care. Patients should be as free from pain as possible, and can be given proper doses of opioids without fear. For other patients, concerns about addiction should be minimal. If a patient has a history of drug abuse, then he would be at a higher risk than others, but there is a difference between an “addict” and a non-addict. An addict tends to pull away from society; the patient who needs the drug for pain moves back into society as a result of the pain control, which increases activity and energy. In a review of the records of 11,882 hospitalized patients treated with opioids, there were only four cases of addiction in patients with no addiction history.

Note: Tolerance to or physical dependence on opioids, which may develop in a patient on extended opioid therapy, should not be confused with addiction (psychological dependence). For a full discussion, see Drug Abuse and Dependence in the “Prescribing Information” section for the opioid products of The Purdue Frederick Company and Purdue Pharma L.P.


Concern #3

Tolerance to opioids develops rapidly, making it necessary to constantly increase the doses.


Tolerance development is fairly slow, which makes opioids safe to use (if properly prescribed and properly taken).

When used for cancer pain, tolerance to oral morphine (morphine taken by mouth) develops slowly. Tolerance to a drug means that as the body gets used to a drug, it needs more and more of that same drug to get the same effect. Often, when cancer patients have more pain, it is not the increased tolerance level that makes them need more pain medication; it is the progression of the cancer that brings more pain, which increases the need for medication. A study of 205 hospice patients in England with advanced cancer showed that those taking diamorphine over a 6 to 24 week period required only a gradual rise in diamorphine dosing. In this study, the longer a patient took diamorphine, the slower the rise in dose and the longer the periods without a dose increase. All pure opioids have no maximum daily dose or “ceiling” for analgesic effect (dulling pain). This means that opioids can be prescribed in whatever dosages needed, high or low. And, as the tolerance level for opioids increases in a patient, so does the tolerance level for the side effects of nausea, sedation, and confusion. Though a tolerance is developed for some side effects, the side effect of constipation usually remains.


Concern #4

Opioids cause un mangeable constipation.


It is true that constipation is a universal side effect of opioids, but it can be managed.

AHCPR recommends a bowel protocol (plan for clearing and/or taking care of bowels) for patients who may experience marked constipation. There are medications (stool softeners, emollient agents, stimulant laxatives, etc.) that can be used to make bowel movements easier.


Concern #5

Most patients taking opioids also have to take anti-emetics (drugs to prevent nausea and/or vomiting).


Nausea and vomiting are side effects that diminish over the first few days of therapy.

 It is important to determine the cause of nausea and vomiting. Sometimes, especially in cancer patients, nausea and vomiting can result from chemotherapy or disease progression, not just from opioids.Treatment of nausea and vomiting depends on the cause. If a patient complains of nausea after opioids have been taken, then an antiemetic can be administered for a few days and eventually discontinued (and then taken on an “as needs” basis). Sometimes, relief of constipation also helps relieve or moderate nausea and vomiting.


Concern #6

Unacceptable sedation and confusion are frequent side effects.


When patients having moderate to severe pain are given proper doses of opioids, unacceptable sedation and confusion rarely occur.

While sedation and confusion are common when opioid treatment begins, the effects decrease and disappear within a few days. Sedation and confusion typically occur in the first 24-48 hours after the beginning of treatment, and then a tolerance is developed. If sedation persists, the patient and practitioner can work together to find a dosage that balances pain relief and mental clouding.


Concern #7

Short-acting opioids (3 to 6 hours) are the ideal analgesic (pain-killer) for controlling moderate to severe pain.


Controlled-release opioids are ideal for most patients.

Controlled-release opioids offer “around-the-clock” pain management, which allows each dose to become effective before the previous dose has lost its effectiveness. It also keeps patients from having to disrupt daily activities to take medications at just the right times, and it makes taking medication easier to remember, because it only has to be taken a couple of times a day. It is advisable to have supplementary immediate-release opioids on hand in case a patient has incident pain (an accident) or breakthrough.


Concern #8

Controlled-release opioids should only be used for cancer-related pain.


Controlled-release opioids are for patients with moderate to severe pain who require opioid therapy for more than a few days. Administration of controlled-release opioids is based on degree and duration of pain, not on the underlying disease-state.

Controlled-release opioids can be used for back pain, osteoarthritis, post-operative pain, neuropathic pain, fracture/trauma, chronic musculoskeletal pain, AIDS pain, and reflex sympathetic dystrophy (RSD), as well as cancer pain. The Use of Opioids for the Treatment of Chronic Pain issued by the American Academy of Pain Medicine and the American Pain Society serves as a guide for practitioners who choose to treat chronic pain with opioids.


Concern #9

Beginning with and finding the right dose is difficult to do with controlled-release opioids.


Finding the right doses, including the starting amount, is straightforward.

For patients who are not currently using opioids:

·        Start with the lowest possible dose of controlled-release preparation, plus supplemental immediate-release preparation as needed for breakthrough pain.

·        Titrate (balance and/or increase) doses using the following “TIME” guideline:

·        Titrate patients every 1-2 days (number of days depends on the particular controlled-release drug)

·        Increase the dose by 25-50% if necessary – do not increase the dosing frequency.

·        Manage breakthrough pain with a supplemental immediate-release opioid at ¼ -1/3 of the 12-hour controlled-release dose.

·        Elevate controlled-release dose if more than 2 supplemental doses are required per day.


For patients who are already taking other opioids:

·        Convert from prior opioid to a dose that will give the same amount of pain relief.

·        Titrate according to the “TIME” guideline above.


Concern #9

If cancer pain is severe, opioids must not be taken orally, but by other methods (injections or rectally).


The AHCPR says that taking medication orally is the preferred route for pain relief.

Taking medication by mouth is convenient, less expensive, and keeps the patient independent. According to one study, only 15% of patients require injections before the last 2-3 days of life.


Concern #10

Plasma opioid concentrations correlate directly with the level of analgesia.


There is no exact correlation between plasma opioid concentration and analgesia.

With all opioids, the minimum effective plasma concentration for analgesia will vary widely among patients, especially among those who have been previously treated with potent agonist opioids. As a result, patients need to be treated with individualized doses to the desired effect. They can be dosed as high as necessary to achieve pain relief.

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