Opioids in chronic noncancer pain: more faces from the crowd

Abstract

Background: The use of opioids for chronic noncancer pain (CNCP) remains very controversial. There are several randomized controlled trials, mostly in neuropathic pain, reporting efficacy and safety in the short term, but more long-term data are needed. Randomized controlled trials may be limited in providing data about the patients who benefit from often high-dose opioids over the long term. The present article provides details of these patients and adds to a previous case series.

Methods: The present article contains 17 case reports of 11 CNCP conditions (followed to 2011) selected to illustrate specific issues from a survey of 84 patients with intractable CNCP treated with opioids and followed every three months for a median of 11 years. The previous published survey of this group reported outcomes of pain severity, adverse effects, pain relief, satisfaction, mood, problematic opioid use, tolerance, physical dependency, functional status, health-related quality of life (HRQL), immune status and sexual function. The outcome measures for that study included a numerical rating scale for pain, the Hospital Anxiety and Depression Scale, the Brief Pain Inventory Interference Scale, the Pain Disability Index and, for HRQL, the Short-Form Health Survey 12 version 2. Most patients in the total sample reported 50% or greater relief and a moderate improvement in disability. Scores for functional status and HRQL were not severely affected. Problematic use, tolerance and serious adverse effects, including constipation, were not major issues. These selected patient reports were chosen, not to illustrate optimal results, but rather important aspects of the diagnoses, opioids and doses, the paucity of intolerable adverse effects, particular issues (concurrent addiction history, bipolar disorder and combination therapy), disease-specific and other outcomes and duration of follow-up with complex pain problems.

Results: Opioids were found to be safe and useful in the long term for these particular patients, as well as in the larger group from which they originated.

Interpretation: These 17 reports of patients with intractable CNCP treated with opioids with some success over many years puts a face on more of the participants in the larger survey of 84 subjects, suggesting that this approach is effective and safe for some patients over many years.

Figure 1)

Newspaper headline from Toronto, Ontario, regarding long-acting oxycodone

Figure 2)

Case 1: CM seen with bearded dragon ‘Spike’. She was diganosed with mechanical low back pain and treated with high-dose oxycodone

Figure 3)

Case 2: On high-dose opioids for back and neuropathic leg pain, VD has been able to enjoy being with his grandchildren for many years. He was previously bedridden

Figure 4)

Case 3: Top KM works full-time with back and neuropathic leg pain while on long-term combination opioids (fentanyl/oxycodone). Bottom Back and neuropathic leg pain on opioids at play

Figure 5)

Case 5: JF has painful diabetic neuropathy, distal loss of pinprick, cold, touch and vibration sensation below the solid line in a long stocking distribution, no ankle reflexes and no motor deficit. Allodynia is present over the dorsal and plantar foot (arrows)

Figure 6)

Case 6: RJ found relief of postherpetic neuralgia with opioids. Arrows: loss of sensation and allodynia in ophthalmic division of V nerve, corneal and uveal inflammation and amaurosis

Figure 7)

Case 7: MF found relief of progressive neuropathic pain due to brachial plexus avulsion (atrophic, arreflexic, paralyzed arm [arrows]) by a combination of an opioid in a low dose (oxycodone) and a tricyclic anti-depressant (nortriptyline) over many years

Figure 8)

Case 8: DW has a long history of bilateral phantom pain following bilateral above-knee amputations (arrows) with relief by long-term low-dose opioids for many years

Figure 9)

Case 9: WC experiences phantom limb pain, with incomplete but significant relief with high-dose opioids (oxycodone) over many years Arrow: painless stump, scapula preserved

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Case 10: MR (left) has iatrogenic infraorbital nerve causalgia Arrow: infraorbital nerve sensory loss

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Case 11: SD with causalgia due to bullet wound, moderate relief with high-dose opioids (morphine) over many years. Lines: sensory loss right face; Arrow: main pain in malar region

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Case 12: DQ found relief from chronic inflammatory pain due to osteomyelitis with moderate-dose opioids (short-acting oxycodone) and a supportive brace over years. Arrow: draining sinus

Figure 13)

Case 16, JT: Recreational activity possible with relief of chronic post-traumatic orthopedic pain with low-dose opioid (oxycodone)