Hi, welcome back. This is James Fricton again, and again want to encourage you to consider joining me in International Mayo Pain Society I'm currently president, and so I'd like to put a plug in for them, it's a wonderful organization with good group, good group of people. This part four is to talk about what about opioid analgesics for chronic pain. As I mentioned the previous part, we really want to start with treatments that have minimal risk. So the question is, are opioid analgesics appropriate for chronic pain? And if so when are they appropriate? So should we give Mona Lisa opioids for her chronic pain? After all it really is a strong pain killer, and this is what most doctors do with initial acute pain. So as we found opioids are widely used for acute pain typically for moderate severe pain conditions. Often when non-opioids which are often tried first are inadequate, frequently used for post-surgical pain, for acute musculoskeletal injuries, as in Mona Lisa's case, dental pain from abscesses and extractions and cancer pain. And a variety of other types of pain problems too, including chronic pain in many cases. But do opioids they do show, short-term relief for musculoskeletal pain. So there's a variety of studies have been done here's a summary of six trials with, a systematic review of six trials showing 1,887 participants. And this systematic review demonstrated that opioids were clearly better than placebo for short term relief of back pain with moderate quality evidence. So it does work. At least short term. And most doctors agree. In this study, 42% of workers with back injuries receive opioids at their first visit. And unfortunately, 16% were still on opioids at one year. Now, what does that tell you? And as we know with opioids if you've used them in the past that they do have a number of side effects. And here is the differences between a study that was done between opioids compared to placebo adverse events. And those with more than one adverse events, you can see that even placebo had 30% with some adverse events. But adverse event withdrawal you could see the percentage there, over 20%. Lack of efficacy withdrawal, so in other words, they stopped the medication due to adverse events, or lack of efficacy. They had a dry mouth, over 20%, nausea, over 20%, constipation, over 10%, itching or pruritus, over 10%. Dizziness, drowsiness or fatigue, and vomiting in some situations. So there's a lot of adverse events. And we have to be cautious about that with regard to use of opioids. And then of course, when there are risk factors that are present such as depression, stress, post traumatic stress repetitive strain are present. Opioids can lead to many other problems. They not only can have continued adverse events, but escalating dosages because it becomes less effective over time. There's dependency that can occur and illicit drug use by others. Frequently, there are people in the family and friends who use the medications that were given to the, the patient. There's a potential for overdosing and significant ora, organ damage if it's combined with acetaminophen or with an anti-inflammatory. So ultimately, opioid abuse can become a huge problem. The numbers in our society in the United States show that the number of drug overdose deaths from opioids were 40,000. The unintentional overdose deaths was 15,000, unintentional opioid death. Non medication use of prescriptions was estimated to be 12 million. And related cost to insurance 72 billion due to the complications from opioids. Emergency room visits from adverse events a half a million. And total workers compensation costs related to opioids is about 15 to 20% of all costs is related to opioids and their adverse events. So, what about chronic pain? Does it work long term for patients with back pain, or headaches, shoulder pain? Unfortunately the studies have demonstrated that it may not. So two trials show that anti-inflammatories, NSAIDs, had equal pain relief to opioids. Study one was with 796 patients, and 63.2 had relief with NSAIDs versus 49.9 with opioids. In study number two, 802 patients, we only had, we had 64% had relief with NSAIDs versus 55.1 with opioids. So it doesn't seem to work that much better than anti inflammatory medications. Plus there was much fewer adverse events in the NSAID group. Now look at this forest plot for a second. Again, three studies, comparing opioids versus NSAIDs and you can see that the diamond is right down the middle and each of the studies down the middle so it does not show that opioids have any better efficacies than NSAIDs. So, should I use opioids for Madame Lisa. Well, the indications for opioids are intractable pain after, for instance, multiple surgeries. Severe constant pain for several months. Pain that interferes with function and daily activities. And past unsuccessful trial with non-opioid analgesics. And there are several contraindications also, including allergy, COPD, a current history of addic, current or history of addiction to opioids or other drugs, and of course, significant adverse events. So if we were to use opioids, what are some of the guidelines that we should follow in order to minimize these types of adverse events? Well, we typically work with our patients with a written agreement between the doctors and the patients about the use of opioids. An agreement should include these nine factors, goals, expectations, consequence, benefits, risks should all be spelled out in very clear, simple language. That the opioids need to be for intractable pain or acute musculoskeletal pain. It needs to be used only as an adjunct as part of a comprehensive care program. We always review the state pharmacy register to make sure the patient is not taking from multiple sources. Five is stay on the stable effective dose with long term goal direct treatment and you need to accomplish something. You need a better function, reduction in pain and that has to be documented fairly clearly. We only allow for one prescriber and one pharmacy to provide the patients with the opioid medications, otherwise it gets confusing. And we maintain regular visits for prescriptions with no phone refills. We discontinue use if the agreement is broken or the goals not achieved. And finally we want to maintain very good documentation. And particularly document any irregularity of its use. So these are some of the factors that we will look at with regard to opioid use for patients with intractable, chronic pain. But in general, I believe that it's really not a, a very helpful treatment for the majority of patients. Thank you. [BLANK_AUDIO]
