Just How Effective Are Opioids In Neuropathy Treatment

Today's post from medpagetoday.com (see link below) is an interesting review of a large-scale study of the effects of opioid treatment on people with neuropathy. It concludes that opioid use has its limitations but there is no evidence that it is either, over-prescribed by doctors, or abused by patients. This removes it immediately from the current hysteria concerning opioid medication and recognises that people with severe neuropathy have very few options. As a result, it calls for new medication development, not to remove the 'evils' of opioids but to provide a better alternative for patients in chronic pain. Definitely worth a read though maybe a little disheartening for people who rely on opioids to dampen their symptoms, having already exhausted all other options.

Long-Term Opioids May Not Help in Polyneuropathy
by Kristin Jenkins Contributing Writer, MedPage Today May 23, 2017 Reviewed by Henry A. Solomon, MD, FACP, FACC Clinical Associate Professor, Weill Cornell Medical College and Dorothy Caputo, MA, BSN, RN, Nurse Planner last updated 05.23.2017
 
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Long-term opioid therapy among patients with polyneuropathy appears to increase the risk of adverse outcomes without benefiting functional status, according to a retrospective population-based study.
Note the data agree with prior studies showing opioid use disorders are more prevalent among those receiving long-term opioid therapy, but did not indicate that long-term opioid therapy significantly increases mortality among patients with polyneuropathy as it does among broader populations of patients reported elsewhere.


Long-term opioid therapy in patients with polyneuropathy appears to increase the risk of adverse outcomes without benefiting functional status, researchers said.

Data from a retrospective, population-based cohort study showed that 18.8% of 2,892 patients with polyneuropathy received opioids continuously for at least 90 days compared to 5.4% of 14,435 controls. They were also more likely to rely on gait aids and have difficulty climbing stairs (adjusted HR 1.7) and experience depression (adjusted HR 1.53), opioid dependence (aHR 2.85), and opioid overdose (aHR 5.12) compared to controls, Christopher J. Klein, MD, of the Mayo Clinic in Rochester, Minn, and colleagues reported online in JAMA Neurology.

"By showing that polyneuropathy increases the risk of long-term opioid therapy and that long-term opioid therapy is not associated with improved functional status but is associated with adverse outcomes, this study provides useful information to counsel patients with polyneuropathy who are considering or are already receiving opioid therapy," the researchers said. "Furthermore, it provides evidence that could influence treatment guidelines and health policy."

The researchers also reported that a diagnosis of opioid abuse among patients with polyneuropathy who were taking opioids for any length of time was observed in less than 2% of patients and that there was no significant association with overall mortality. However, there was a 7.2% rate of opioid dependence and a 2.6% rate of opioid overdose, they pointed out, adding that this "underscores that abuse and dependence are not synonymous."

"Thus, our results agree with those of prior studies citing that opioid use disorders are more prevalent among those receiving long-term opioid therapy, but we did not find that long-term opioid therapy significantly increases mortality among patients with polyneuropathy as it does among broader populations of patients reported elsewhere.

Importantly, the study also showed that neurologists and pain physicians were only prescribing long-term opioid therapy in a small percentage of patients, a finding consistent with national trends, the researchers noted. "Therefore, it is likely that discussing potential benefits, as well as adverse outcomes, of long-term opioid therapy will fall to the primary care clinician," Klein and colleagues said.

For the study, the Rochester Epidemiology Project (REP) database was searched for prescriptions given to patients with polyneuropathy and for those given to controls in ambulatory practice. All data came from participants who resided in Olmsted County from Jan. 1, 2006, to Dec. 31, 2010 and were reported previously. The latest follow-up ended Nov. 25, 2016.

Patients with polyneuropathy receiving 90 days or more of opioid therapy were more likely to be female (57%) than those receiving short-term opioid therapy (P<0 .001="" 46="" 69="" age="" also="" although="" between="" br="" common="" commonly="" differences="" documented="" for="" groups="" in="" indication="" long-term="" median="" most="" musculoskeletal="" no="" of="" opioid="" oxycodone="" p="0.13)." pain="" patients="" polyneuropathy="" prescribed="" prescribing="" significant="" similar="" starting="" the="" therapy.="" there="" trends="" two="" versus="" were="" with="" xycontin="" years="">
Although rates of lower limb complications were comparable between the two groups, patients with polyneuropathy used non-opioid analgesics more often than controls.

In an accompanying editorial, Nora Volkow, MD, of the National Institute on Drug Abuse, and Walter Koroshetz, MD, of the National Institute of Neurologic Disorders and Stroke, noted that opioids in this study were prescribed more often for treatment of non-neuropathic indications. However, this finding doesn't change the evidence behind current guidelines advising against opioids as first-line treatment in most cases of neuropathic pain because of long-term safety concerns, they said.

The study also highlights the limited alternatives for managing chronic pain, and the urgent need to develop new medications, the editorialists said. Recent work in animal models demonstrate that innovative opioid peptides and biased opioid agonists may provide equivalent pain relief with less tolerance and fewer adverse effects while success with biologics for inhibiting pain at the its source may shift the focus to prevention, they said.

"In the meantime, structural changes in the healthcare system, including training of physicians in the screening and management of pain, as well as coverage by insurance of comprehensive pain management programs, are needed to ensure that patients receive the most effective treatments for their chronic pain conditions," Volkow and Koroshetz said.

Limitations of the study include the fact that it was based on prescription data without confirmation that prescriptions were filled or taken as intended.


This study was funded by the Mayo Foundation for Medical Education and Research, Mayo Clinic Center for Individualized Medicine, and the National Institutes of Health (NIH). The study authors disclosed no conflicts of interest. The editorialists disclosed no funding or conflicts of interest.

https://www.medpagetoday.com/neurology/painmanagement/65497

Is It Wise To Dismiss Opioids For Chronic Pain

Today's post from thebodypro.com (see link below) is directed at people living with HIV and chronic pain conditions such as neuropathy (around 40% of HIV patients also suffer from nerve damage) but also applies to the general population if they have a chronic pain condition - irrespective of the cause. That said, the article comes over as a little confused; as if the author isn't sure on which side of the fence she sits regarding opioid prescription and use. The underlying message that opioid prescription should be a last resort for chronic pain is indisputable but the idea that the cause of the pain should first be dealt with, is simply inapplicable to people with most chronic pain conditions for which there is no cure and certainly for HIV patients, cancer patients and the like. She also suggests that evidence of opioid effectiveness is limited, when there are countless studies that show that opioids are an extremely effective way of suppressing pain...if handled properly, with sufficient after-care. She also rolls out the addiction problem: "evidence of their risks is mounting, with an estimated 10% of patients on such medications becoming addicted"! Surely this advances the efficacy of opioids because by definition, 90% of patients do not become addicted!! Whether this article will change your opinion on opioids is for you to decide but when it comes to chronic pain conditions, the idea that they can be treated just with behaviour change, is way too simplistic. Experienced neuropathy patients will know all too well the hoops they have to jump through in order to get their pain under control and are well aware of the gamut of other dangerous medications they have to try before reaching the opioid stage. Fear of opioids may lead to much more unnecessary suffering than is needed.

Opioids Are Not a First-Line Treatment for Chronic Pain, Pain Specialist Says
By Barbara Jungwirth From TheBodyPRO.com October 6, 2016



When someone living with HIV complains about chronic pain, take their word for it, but try non-opioid therapies and treat underlying psychiatric illnesses before prescribing oxycodone, Jessica S. Merlin, M.D., M.B.A., advised health care providers in a recent webinar. People living with HIV are more likely to suffer from such pain (30%-85% report chronic pain) than the general population (15% report that issue). This may be partly due to greater sensitivity to pain in those with detectable viral loads, Merlin explained.

Providers must understand the impact that this condition has on a patient's daily life, screen for mood disorders and note the patient's coping strategies before suggesting a therapy approach, Merlin advised in the Chronic Pain in HIV Infection: A Practical, Evidence-Based Approach webinar sponsored by the International Antiviral Society-USA on August 18, 2016. An effective technique Merlin has used in her chronic pain clinic is motivational interviewing, which is designed to stimulate people's own motivation for change, rather than simply telling them that they should change their behavior. She counseled providers to educate patients about ways to control pain without resorting to prescription medications, including mind-body techniques and short-term, over-the-counter drugs, such as acetaminophen. The latter, however, has problematic side effects when taken long-term, especially in combination with antiretrovirals, Merlin cautioned. Other approaches include physical therapy and exercise, as well as topical medications.

Providers should develop a team either within their office or within the community; it should include mental health professionals, methadone programs and social workers, among others. Such a team approach allows for better screening and treatment of depression, PTSD and other conditions that may co-occur with chronic pain. These problems need to be addressed first to remove the underlying cause of the pain, rather than treating only the symptoms.

Opioids should not be considered first-line therapy for chronic pain, Merlin emphasized. Evidence of their benefit is limited, and no studies have evaluated their use for longer than one year. By contrast, evidence of their risks is mounting, with an estimated 10% of patients on such medications becoming addicted, as well as a risk of overdose, especially when co-prescribed with benzodiazepines. Providers should take universal precautions when prescribing opioids, rather than deciding who is or is not at risk of opioid use disorder. These precautions include having the patient sign an opioid treatment agreement, with provisions for using only one prescriber and one pharmacy and submitting to frequent urine drug testing. However, urine tests can result in false positives, especially when someone takes multiple medications, as is the case with those living with HIV, Merlin noted. A confirmatory assay, as well as a conversation with the patient, are therefore necessary before jumping to conclusions.

If all non-opioid attempts at managing the chronic pain have failed and oxycodone or a similar drug is prescribed, the lowest effective dose should be used. Patients should be re-assessed at least every three months, other therapies should be optimized, and the opioid dosage prescribed should be tapered off over time with the goal of eventually discontinuing it altogether. Merlin also advocated co-prescribing naloxone for high-risk patients, if they can bring in someone who lives with them and can administer the antidote in case of opioid overdose. However, local laws differ as to whether this approach is permitted. Laws on marijuana use also differ among states, but where legal the substance may be useful in treating chronic pain. Evidence shows that people who are prescribed medical marijuana use opioids less, reducing the risks associated with opioids.

Barbara Jungwirth is a freelance writer and translator based in New York.

Follow Barbara on Twitter: @reliabletran.

http://www.thebodypro.com/content/78544/opioids-are-not-a-first-line-treatment-for-chronic.html

Opioids can Erase Memory Traces of Neuropathy Pain

This fascinating new article from ScienceDaily.com (see link below) throws new light on the potential of opioids to tackle (amongst others) neuropathic pain. It claims that at the right doses and right administration, the 'memory' of pain in the spinal cord can be eliminated. Instead of taking pills every day over an extended period of time, thus leading to potential addiction; this study proposes high doses of injected opioids over the period of one hour. In this way, the cellular memory of pain is then deleted and extended chronic pain sensations can be completely removed. Whether the treatment needs to be repeated is not entirely clear. Fascinating stuff but of course cynical neuropathy sufferers will always say that seeing is believing and it seems that we're a long way off this becoming standard treatment for chronic pain.

Opioids Erase Memory Traces of Pain
ScienceDaily (Jan. 13, 2012)

A team of researchers at the MedUni Vienna's Department of Neurophysiology (Centre for Brain Research) has discovered a previously unknown effect of opioids: the study, which has now been published in the journal Science and was led by Ruth Drdla-Schutting and Jürgen Sandkühler, shows that opioids not only temporarily relieve pain, but at the right dose can also erase memory traces of pain in the spinal cord and therefore eliminate a key cause of chronic pain.

scientists recreated a surgical procedure in vivo in which pain fibres were stimulated under controlled conditions.

Says Sandkühler: "Although deep anaesthesia prevents any sensations of pain, we were able to reserve long-term synaptic potentiation in the spinal cord. Despite anaesthesia, there appears to be a memory trace for pain and a pain amplifier has engaged." High doses of intravenous opioids over the course of an hour -- normally opioids are delivered at moderate doses over a longer period -- were able to completely resolve the potentiation. Says Sandkühler: "The memory trace for pain was therefore deleted again and the pain amplifier switched off."

The memory trace, as it is termed, is triggered by a variety of mechanisms, including the potentiation of signal transmission at the contact points (synapses) between the nerve cells. This is known as long-term synaptic potentiation. This pain memory can result in the sensation of amplified pain lasting much longer than the actual cause of the pain, even leading to a condition known as chronic pain syndrome.

A paradigm shift in pain therapy?

The project, which is sponsored by the Vienna Fund for Science, Research and Technology (WWTF), is currently investigating how this discovery can be put to use in clinical settings. To this end, test subjects or patients with pain syndrome are being given a high dose of an opioid over a period of 60 minutes.

"If our approach turns out to be effective under clinical conditions, this would herald a paradigm shift in pain therapy. It would mean moving away from the temporary, purely symptom-based pain therapy to a long-term removal of the cause of pain based on pain mechanisms using opioids."

The effect of opioids (morphine or morphine-like substances) is based on their ability to bind to specific binding sites, known as µ-opiate receptors (MOR) which are found on nerve cells and which process pain-related information. Until now, it has been assumed that opioids are only able to alleviate pain while they are bound to the MOR and therefore suppress stimulation in the pain-processing system. Says Drdla-Schutting: "As soon as the medication is stopped, the pain-relieving effect disappears too." In clinical practice, opioids are therefore given continuously in moderate doses in order to achieve permanent binding to the MOR. This may relieve pain very effectively, but its cause cannot be eliminated. The new, high-dose, short-term therapy with opioids, on the other hand, causes a reversal of cellular changes that play an important role in pain memories, therefore possibly eliminating one of the causes of chronic pain.

http://www.sciencedaily.com/releases/2012/01/120113204933.htm