Seddon R. Savage

Methadone Safety: A Clinical Practice Guideline From the American Pain Society and College on Problems of Drug Dependence, in Collaboration With the Heart Rhythm Society

UNLABELLED Methadone is used for the treatment of opioid addiction and for treatment of chronic pain. The safety of methadone has been called into question by data indicating a large increase in the number of methadone-associated overdose deaths in recent years that has occurred in parallel with a dramatic rise in the use of methadone for chronic pain. The American Pain Society and the College on Problems of Drug Dependence, in collaboration with the Heart Rhythm Society, commissioned an interdisciplinary expert panel to develop a clinical practice guideline on safer prescribing of methadone for treatment of opioid addiction and chronic pain. As part of the guideline development process, the American Pain Society commissioned a systematic review of various aspects related to safety of methadone. After a review of the available evidence, the expert panel concluded that measures can be taken to promote safer use of methadone. Specific recommendations include the need to educate and counsel patients on methadone safety, use of electrocardiography to identify persons at greater risk for methadone-associated arrhythmia, use of alternative opioids in patients at high risk of complications related to corrected electrocardiographic QTc interval prolongation, careful dose initiation and titration of methadone, and diligent monitoring and follow-up. Although these guidelines are based on a systematic review, the panel identified numerous research gaps, most recommendations were based on low-quality evidence, and no recommendations were based on high-quality evidence. PERSPECTIVE This guideline, based on a systematic review of the evidence on methadone safety, provides recommendations developed by a multidisciplinary expert panel. Safe use of methadone requires clinical skills and knowledge in use of methadone to mitigate potential risks, including serious risks related to risk of overdose and cardiac arrhythmias.

Clinical realities and economic considerations: Special therapeutic issues in intrathecal therapy—tolerance and addiction

The long-term use of opioid analgesics in chronic nonmalignant pain has long been controversial. Rational discussion has been impeded by outdated research and myths regarding the risks of this therapy. Some of the misconceptions relate to the inappropriate use of the terms tolerance and addiction. Analgesic tolerance is a phenomenon in which exposure to the opioid itself causes the patient who has achieved analgesia to require a higher dosage to maintain the same level of effect. This appears to be very uncommon in the clinical setting. A need for dose escalation results from factors other than tolerance, including disease progression. Addiction is an association of psychological dependence and aberrant drug-related behaviors. Addiction to opioids in the context of pain treatment is rare in those with no history of addictive disorder. Clinicians need to become aware of the new findings regarding the low risk of addiction and tolerance in this setting.

A Pain Research Agenda for the 21st Century

UNLABELLED Chronic pain represents an immense clinical problem. With tens of millions of people in the United States alone suffering from the burden of debilitating chronic pain, there is a moral obligation to reduce this burden by improving the understanding of pain and treatment mechanisms, developing new therapies, optimizing and testing existing therapies, and improving access to evidence-based pain care. Here, we present a goal-oriented research agenda describing the American Pain Societys vision for pain research aimed at tackling the most pressing issues in the field. PERSPECTIVE This article presents the American Pain Societys view of some of the most important research questions that need to be addressed to advance pain science and to improve care of patients with chronic pain.

Informed Consent in Opioid Therapy: A Potential Obligation and Opportunity

Most patients receiving opioids for the spectrum of pain disorders tolerate opioids well without major complications. However, a subset of this population encounters significant difficulties with opioid therapy (OT). These problems include protracted adverse effects, as well as misuse, abuse, and addiction, which can result in significant morbidity and mortality and make informed consent an important consideration. Opioid treatment agreements (OTAs), which may include documentation of informed consent, have been used to promote the safe use of opioids for pain. There is a debate regarding the effectiveness of OTAs in reducing the risk of opioid misuse; however, most practitioners recognize that OTAs provide an opportunity to discuss the potential risks and benefits of OT and establish mutually agreed-on treatment goals, a clear plan of treatment, and circumstances for continuation and discontinuation of opioids. Informed consent is an important component of an OTA but not often the focus of consideration in discussions of OTAs. This article examines the principles, process, and content of informed consent for OT of pain in the context of OTAs.

Cannabis in Pain Treatment: Clinical and Research Considerations

UNLABELLED Cannabinoids show promise as therapeutic agents, particularly as analgesics, but their development and clinical use has been complicated by recognition of their botanical source, cannabis, as a substance of misuse. Although research into endogenous cannabinoid systems and potential cannabinoid pharmaceuticals is slowly increasing, there has been intense societal interest in making herbal (plant) cannabis available for medicinal use; 23 U.S. States and all Canadian provinces currently permit use in some clinical contexts. Whether or not individual professionals support the clinical use of herbal cannabis, all clinicians will encounter patients who elect to use it and therefore need to be prepared to advise them on cannabis-related clinical issues despite limited evidence to guide care. Expanded research on cannabis is needed to better determine the individual and public health effects of increasing use of herbal cannabis and to advance understanding of the pharmaceutical potential of cannabinoids as medications. This article reviews clinical, research, and policy issues related to herbal cannabis to support clinicians in thoughtfully advising and caring for patients who use cannabis, and it examines obstacles and opportunities to expand research on the health effects of herbal cannabis and cannabinoids. PERSPECTIVE Herbal cannabis is increasingly available for clinical use in the United States despite continuing controversies over its efficacy and safety. This article explores important considerations in the use of plant Cannabis to better prepare clinicians to care for patients who use it, and identifies needed directions for research.

Recommendations for the Prevention, Detection, Treatment and Management of Prescription Opioid Analgesic Dependence: Outcomes From the Opioid Analgesic Dependence Education Nexus (OPEN) Meeting

The global consumption of opioids continues to rise, which has led to an increasing rate of diversion, misuse, addiction, and deaths related to prescription opioids. This has been particularly well documented in the USA; however, opioid analgesic dependence (OAD) is an increasing concern in Europe. More guidance is required for European healthcare professionals in the prevention, detection, treatment and management of OAD. The first Opioid Analgesic Dependence Education Nexus (OPEN) Mentor Meeting was held in Berlin in September 2014 to address this. An international Expert Panel, combining expertise in OAD from Australia, USA and Europe, invited 16 European experts in the pain and addiction fields to develop a best-practice approach to OAD that European practitioners can adopt. The outcomes from this meeting are presented here and included are a set of shared strategies that may be universally adopted by all healthcare professionals working with patients who use opioids.

The Patient-Centered Opioid Treatment Agreement

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Clinical case discussion: chronic pain management.

Initial Evaluation A 32-year-old white female presents for management of chronic nonmalignant pain with chronic mastalgia from fibrocystic breast disease, anxiety with strong histrionic personality traits, and problems with medication management. The patient’s breast pain began 7 years ago with recurrent duct infections in her left breast. She underwent multiple outpatient and inpatient procedures for drainage of abscesses. The pain in her breasts is bilateral, worse on the left than right, and radiates to the left side of her neck. She characterizes the pain as sharp and stabbing or feeling like a weight on her chest. The pain is constant with variable intensity and her pain level range is 6/10 to 10/10 with an average pain level of 8/10 and a tolerable pain level of 6/10 for her. The pain is worse with raising her arm, lifting heavy objects, cold weather, and during her menstrual period. In addition, she reports being stiff and tense all the time. She reports improvement of her pain with opioids. Despite complaints of significant pain, she is able to do all necessary housework and care for 4 children. The patient reports having tried multiple short-acting opioids and has obtained the best relief with oxycodone/ acetaminophen, taking 1 tablet 6 times daily. She also reports having been prescribed methadone 5-mg tablets to take 3 times daily, but takes a half tablet up to 3 times daily when she feels she needs it. She considers the oxycodone/acetaminophen to be her primary pain medication. She reports that nonsteroidal anti-inflammatory drugs have been ineffective for her pain. She tried gabapentin at a dose of 300 mg twice daily, but this made her tired and she is not interested in trying gabapentin again. Nortriptyline also made her tired and topical lidocaine patches did not provide significant relief. She tried several different oral contraceptive pill brands, but these did not provide pain relief and caused nausea and weight gain. In addition to methadone and oxycodone/acetaminophen, her only other medication is sertraline. The patient reports having taken medication, including opioids, prescribed for other people. She has obtained multiple opioid prescriptions from different physicians at the same time. She has cancelled or failed to appear for multiple clinic appointments, then has called requesting prescriptions for short-acting opioids. The patient has a history of binge drinking in high school but reports that she currently consumes one alcoholic drink per month. She smokes a half-pack of cigarettes per day, which she has done for the past 18 years. She experimented with smoking marijuana in high school but denies other illicit drug use. The patient’s medical history includes fibrocystic breast disease, carpal tunnel syndrome, and asthma. Surgical history includes one cesarean section and a tubal ligation. The patient has an 11th-grade education and currently works as a homemaker living with her husband and 4 children, ages 1 to 11 years. She has a history of reactive depression caused by financial problems and childcare responsibilities. She was raped at age 15 years. She has a history of significant emotional stress with poor coping skills and histrionic personality traits with behavior that fluctuates from seductive to angry and needy.