Jump to ContentJump to Main Navigation
Show Summary Details
More options …

Scandinavian Journal of Pain

Official Journal of the Scandinavian Association for the Study of Pain

Editor-in-Chief: Breivik, Harald


CiteScore 2017: 0.84

SCImago Journal Rank (SJR) 2017: 0.401
Source Normalized Impact per Paper (SNIP) 2017: 0.452

Online
ISSN
1877-8879
See all formats and pricing
More options …
Volume 17, Issue 1

Issues

Long-term treatment in chronic noncancer pain: Results of an observational study comparing opioid and nonopioid therapy

Karin Elsesser / Thomas Cegla
Published Online: 2017-10-01 | DOI: https://doi.org/10.1016/j.sjpain.2017.07.005

Abstract

Background and aims

Recent studies reveal high prevalence rates of patients receiving long-term opioids. However, well designed studies assessing effectiveness with longer than 3 months follow-up are sparse. The present study investigated the outcomes of long-term opioid therapy compared to nonopioid treatment in CNCP patients with respect to measures of pain, functional disability, psychological wellbeing, and quality of life (QoL).

Methods

Three hundred and thirty three consecutive patients at our pain clinic were included and divided into patients with continuous opioid treatment for at least 3 months (51%) and patients receiving nonopioid analgesics (49%). Further, outcome of different doses of opioid (<120 mg vs. >120 mg morphine equivalents) and differences between high and low potency opioids were examined.

Results

The opioid and nonopioid groups did not differ with regard to pain intensity or satisfaction with analgesic. Patients with continuous opioids treatment reported higher neuropathic like pain, longer duration of pain disorder, lower functional level, wellbeing, and physical QoL in comparison to patients receiving nonopioid analgesics. Higher opioid doses were associated with male gender, intake of high potency opioids and depression but there were no differences with regard to pain relief or improvement of functional level between high and low doses. Similarly, patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief. Overall, remaining level of pain, functional disability and poor QoL were quite high irrespective of the analgesic used or opioid dosing.

Conclusions

In the long-term no clear advantage of opioid vs. non-opioid analgesics could be revealed. In terms of remaining pain intensity, functional disability and quality of life, treatment with pain medication proved insufficient. Additionally, with higher doses of opioids the benefit to risk relationship becomes worse and patients on high potency opioids reported more psychological impairment than patients on low potency opioids but no advantage with regard to pain relief.

Implications

Our results raise questions about the long-term effectiveness of analgesic treatment regimens irrespective of analgesics type employed and call for more multidisciplinary treatment strategies.

Keywords: Long-term opioid therapy; Chronic pain; Quality of life; Functional outcome; Psychological wellbeing

References

  • [1]

    Schubert I, Ihle P, Sabatowski R. Increase in opiate prescription in Germany between 2000 and 2010: a study based on insurance data. Dtsch Ärztebl Int 2013;110:45–51.PubMedGoogle Scholar

  • [2]

    Sullivan MD, Howe CQ. Opioid therapy for chronic pain in the United States: promises and perils. Pain 2013;154 (Suppl.1):S94–100.CrossrefPubMedGoogle Scholar

  • [3]

    Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ 2006;174:1589–94.CrossrefGoogle Scholar

  • [4]

    Bailey RW, Vowles KE. Chronic noncancer pain and opioids: risks, benefits, and the public health debate. Prof Psychol Res Pract 2015;46:340–7.CrossrefGoogle Scholar

  • [5]

    Maier C, Schaub C, Willweber-Strumpf A, Zenz M. [Long-term efficiency of opioid medication in patients with chronic non-cancer associated pain. Results of a 5 years survey after onset of medical treatment].Schmerz 2005;19:410–7.Google Scholar

  • [6]

    Jensen MK, Thomsen AB, H0jsted J. 10-year follow-up of chronic non-malignant pain patients: opioid use, health related quality of life and health care utilization. Eur J Pain 2006;10:423–33.Google Scholar

  • [7]

    Welsch P, Sommer C, Schiltenwolf M, Hauser W. Opioids in chronic noncancer pain-are opioids superior to nonopioid analgesics? A systematic review and meta-analysis of efficacy, tolerability and safety in randomized head-to-head comparisons of opioids versus nonopioid analgesics of at least four week’s duration. Schmerz 2015;29:85–95.PubMedGoogle Scholar

  • [8]

    Kissin I. Long-term opioid treatment of chronic nonmalignant pain: unproven efficacy and neglected safety? J Pain Res 2013;6:513–29.PubMedGoogle Scholar

  • [9]

    Breivik H, Ljosaa TM, Stengaard-Pedersen K, Persson J, Aro H, Villumsen J, Tvinnemose D. A 6-months, randomised, placebo-controlled evaluation of efficacy and tolerability of a low-dose 7-day buprenorphine transdermal patch in osteoarthritis patients naive to potent opioids. Scand J Pain 2010;1: 122-41.CrossrefPubMedGoogle Scholar

  • [10]

    Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Int Med 2015;162:276–86.CrossrefGoogle Scholar

  • [11]

    Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Korff M von. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152:85–92.CrossrefPubMedGoogle Scholar

  • [12]

    Carman WJ, Su S, Cook SF, Wurzelmann JI, McAfee A. Coronary heart disease outcomes among chroni opioid and cyclooxygenase-2 users compared with a general population cohort. Pharmacoepidemiol Drug Saf 2011;20:754–62.CrossrefGoogle Scholar

  • [13]

    Li L, Setoguchi S, Cabral H, Jick S. Opioid use for noncancer pain and risk of fracture in adults: a nested case-control study using the general practice research database. Am J Epidemiol 2013;178:559–69.CrossrefPubMedGoogle Scholar

  • [14]

    Rolita L, Spegman A, Tang X, Cronstein BN. Greater number of narcotic analgesic prescriptions for osteoarthritis is associated with falls and fractures in elderly adults. J Am Geriatr Soc 2013;61:335–40.PubMedCrossrefGoogle Scholar

  • [15]

    Scherrer JF, Svrakic DM, Freedland KE, Chrusciel T, Balasubramanian S, Bucholz KK, Lawler EV, Lustman PJ. Prescription opioid analgesics increase the risk of depression. J Gen Intern Med 2014;29:491–9.CrossrefPubMedGoogle Scholar

  • [16]

    Ballantyne J, Mao J. Opioid therapy for chronic pain. N Engl J Med 2003;349:1943–53.CrossrefPubMedGoogle Scholar

  • [17]

    Lee M, Silverman S, Hansen H, Patel V, Manchikanti L. A comprehensive review of opioid-induced hyperalgesia. Pain Physician 2011;14:145–61.PubMedGoogle Scholar

  • [18]

    Saunders KW, Dunn KM, Merrill JO, Sullivan M, Weisner C, Braden JB, Psaty BM, Korff M von. Relationship of opioid use and dosage levels to fractures in older chronic pain patients. J Gen Intern Med 2010;25:310–5.PubMedCrossrefGoogle Scholar

  • [19]

    Dillie KS, Fleming MF, Mundt MP, French MT. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med 2008;21:108–17.CrossrefGoogle Scholar

  • [20]

    Richardson JL, Marks G, Johnson CA, Graham JW, Chan KK, Selser JN, Kishbaugh C, Barranday Y, Levine AM. Path model of multidimensional compliance with cancer therapy. Health Psychol 1987;6:183–207.PubMedCrossrefGoogle Scholar

  • [21]

    Deutsche Schmerzgesellschaf eV, editor. [German Pain Questionnaire]. Integrative Managed Care GmbH; 2006.Google Scholar

  • [22]

    World Health Organization. The ICD-10 Classification of Diseases, Clinical Descriptions and Diagnostic Guidelines. Geneva WHO; 1992.Google Scholar

  • [23]

    Schmerzklinik Universitàtsmedizin Gòttingen. [Table of opioid-conversion factors]. Available from http://www.ains.med.uni-goettingen.de/sites/default/files/Opioid-Umrechnungstabelle[accessed: 07.06.17].

  • [24]

    Arzneimittelbrief. [Pain therapy with opioids]. AMB 2011; 45 (65).Google Scholar

  • [25]

    Tait RC, Pollard CA, Margolis RB, Duckro PN, Krause SJ. The Pain Disability Index: psychometric and validity data. Arch Phys Med Rehabil 1987;68:438–41.PubMedGoogle Scholar

  • [26]

    Korff M von, Ormel J, Keefe FJ, Dworkin SF. Grading the severity of chronic pain. Pain 1992;50:133–49.CrossrefPubMedGoogle Scholar

  • [27]

    Freynhagen R, Baron R, Gockel U, Tòlle TR. pain DETECT: anew screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin 2006;22:1911–20.CrossrefGoogle Scholar

  • [28]

    Angermeyer MC, Kilian R, Matschinger H. [WHOQOL - 100 und WHOQOL - Bref.Manual for the German Version of WHO instruments for assessment of quality of life]. Gòttingen: Hogrefe Verlag; 2000.Google Scholar

  • [29]

    Bullinger M, Kirchberger I. [SF-36.Short Form Health Survey.Manual]. Gòttingen: Hogrefe Verlag; 1998.Google Scholar

  • [30]

    Herda C, Scharfenstein A, Basler HD. [The Marburg Questionnaire on Habitual Health]. In: Schriftenreihe des Zentrums für Methodenwissenschaften und Gesundheitsforschung. Arbeitspapier 98-1.1998.Google Scholar

  • [31]

    Zigmond AS, Snaith RP. The Hospital Anxiety and Depression Scale. Acta Psychiatr Scand 1983;67:361–70.PubMedCrossrefGoogle Scholar

  • [32]

    Petermann F. Hospital Anxiety and Depression Scale, Deutsche Version (HADS-D). Z Psychiat Psychol Psychother 2011;59:251–3.Google Scholar

  • [33]

    Hauser W, Bock F, Engeser P, Hege-Scheuing G, Huppe M, Lindena G, Maier C, Norda H, Radbruch L, Sabatowski R, Schafer M, Schiltenwolf M, Schuler M, Sorgatz H, Tòlle T, Willweber-Strumpf A, Petzke F. Recommendations of the updated LONTS guidelines. Long-term opioid therapy for chronic noncancer pain.Schmerz 2015;29:109–30.Google Scholar

  • [34]

    Dowell D, Haegerich TM, Chou R. CDC Guideline for Prescribing Opioids for Chronic Pain - United States, 2016. JAMA 2016;315:1624–45.CrossrefPubMedGoogle Scholar

  • [35]

    Chou R, Fanciullo GJ, Fine PG, Adler JA, Ballantyne JC, Davies P, Donovan MI, Fishbain DA, Foley KM, Fudin J, Gilson AM, Kelter A, Mauskop A, onnor PG, Passik SD, Pasternak GW, Portenoy RK, Rich B. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer patients. J Pain 2009;10: 113-30.PubMedCrossrefGoogle Scholar

  • [36]

    Cheung CW, Qiu Q, Choi S, Moore B, Goucke R, Irwin M. Chronic opioid therapy for chronic non-cancer pain: a review and comparison of treatment guidelines. Pain Physician 2014;17:401–14.Google Scholar

  • [37]

    Fredheim OMS, Kaasa S, Fayers P, Saltnes T, Jordhoy M, Borchgrevink PC. Chronic non-malignant pain patients report as poor health-related quality of life as palliative cancer patients. Act Anaesth Scand 2008;52:143–8.Google Scholar

  • [38]

    Bjornsdottir SV, Jonsson SH, Valdimarsdottir UA. Mental health indicators and quality of life among individuals with musculoskeletal chronic pain: a nationwide study in Iceland. Scand J Rheumatol 2014;43:419–23.PubMedCrossrefGoogle Scholar

  • [39]

    Mellbye A, Karlstad O, Skurtveit S, Borchgrevink PC, Fredheim OMS. Comorbidity in persistent opioid users with chronic non-malignant pain in Norway. EurJ Pain 2014;18:1083–93.CrossrefGoogle Scholar

  • [40]

    Christensen HN, Olsson U, From J, Breivik H. Opioid-induced constipation, use of laxatives, and health-related quality of life. Scand J Pain 2016;11: 104-10.CrossrefPubMedGoogle Scholar

  • [41]

    Hauser W, Marschall U, L’hoest H, Komossa K, Henningsen P. Administrative prevalence, treatment and costs of somatoform pain disorder. Analysis of data of the BARMER GEK for the years 2008-2010.Schmerz 2013;27:380–6.Google Scholar

  • [42]

    Kobus AM, Smith DH, Morasco BJ, Johnson ES, Yang X, Petrik AF, Deyo RA. Correlates of higher-dose opioid medication use for low back pain in primary care. J Pain 2012;13:1131–8.CrossrefPubMedGoogle Scholar

  • [43]

    Merrill JO, Korff M von, Banta-Green CJ, Sullivan MD, Saunders KW, Campbell CI, Weisner C. Prescribed opioid difficulties, depression and opioid dose among chronic opioid therapy patients. Gen Hosp Psychiatry 2012;34:581–7.PubMedCrossrefGoogle Scholar

  • [44]

    Marschall U, L’hoest H, Radbruch L, Hauser W. Long-term opioid therapy for chronic non-cancer pain in Germany. EurJ Pain 2016;20:767–76.CrossrefGoogle Scholar

  • [45]

    Braden JB, Sullivan MD, Ray GT, Saunders K, Merrill J, Silverberg MJ, Rutter CM, Weisner C, Banta-Green C, Campbell C, Korff M von. Trends in long-term opioid therapy for noncancer pain among persons with a history of depression. Gen Hosp Psychiatry 2009;31:564–70.CrossrefPubMedGoogle Scholar

  • [46]

    Grattan A, Sullivan MD, Saunders KW, Campbell CI, Korff MR von. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med 2012;10:304–11.CrossrefPubMedGoogle Scholar

  • [47]

    Martel MO, Wasan AD, Jamison RN, Edwards RR. Catastrophic thinking and increased risk for prescription opioid misuse in patients with chronic pain. Drug Alcohol Depend 2013;132:335–41.CrossrefPubMedGoogle Scholar

  • [48]

    Brush DE. Complications of long-term opioi therapy fo management of chronic pain: the paradox of opioid-induced hyperalgesia. J Med Toxicol 2012;8:387–92.CrossrefGoogle Scholar

  • [49]

    Arout CA, Edens E, Petrakis IL, Sofuoglu M. Targeting opioid-induced hyperalgesia in clinical treatment: neurobiological considerations. CNS Drugs 2015;29:465–86.CrossrefPubMedGoogle Scholar

  • [50]

    Perneger TV. What’s wrong with Bonferroni adjustments. BMJ 1998;316:1236–8.PubMedCrossrefGoogle Scholar

  • [51]

    Nakagawa S. A farewell to Bonferroni: the problems of low statistical power and publication bias. Behav Ecol 2004;15:1044–5.CrossrefGoogle Scholar

About the article

Sankt Josef Krankenhaus, Clinic of Pain Medicine, Bergstr. 6-12, 42105 Wuppertal, Germany. angelika.vaupel@cellitinnen.de


Received: 2016-12-21

Revised: 2017-06-29

Accepted: 2017-07-05

Published Online: 2017-10-01

Published in Print: 2017-10-01


Ethical issues: The study was approved by the institutional ethic committee of the University of Wuppertal.

Conflicts of interest: T.C. has received financial support and provided consultant services for the following: Astellas, Grünenthal, Pharmallergan. K.E. has no conflicts of interest to declare.

Funding: This research was supported by funds from Mundipharma GmbH. The funders were not involved in the design and conduction of the study, collection, analysis, interpretation of the data, the writing of the report, and in the decision to submit the article for publication.


Citation Information: Scandinavian Journal of Pain, Volume 17, Issue 1, Pages 87–98, ISSN (Online) 1877-8879, ISSN (Print) 1877-8860, DOI: https://doi.org/10.1016/j.sjpain.2017.07.005.

Export Citation

© 2017 Scandinavian Association for the Study of Pain.Get Permission

Citing Articles

Here you can find all Crossref-listed publications in which this article is cited. If you would like to receive automatic email messages as soon as this article is cited in other publications, simply activate the “Citation Alert” on the top of this page.

[1]
Katri Hamunen
Scandinavian Journal of Pain, 2017, Volume 17, Number 1
[2]
Cristina da Costa Oliveira, Natália Alves de Matos, Clarice de Carvalho Veloso, Gisele Avelar Lage, Lúcia Pinheiro Santos Pimenta, Igor Dimitri Gama Duarte, Thiago Roberto Lima Romero, André Klein, and Andrea de Castro Perez
Inflammopharmacology, 2018

Comments (0)

Please log in or register to comment.
Log in