Share this Article
George JM, Menon M, Gupta P, Tan M
Correspondence: Dr Michelle Tan, email@example.com
INTRODUCTION The use of opioids in chronic non-cancer pain (CNCP) is controversial, as it presents both benefits and risks. There is currently no available data on the incidence, prescription pattern, functional outcomes and adverse effects of opioids in patients with CNCP in Singapore. This study aimed to address the aforementioned deficit.
METHODS All records of patients who were prescribed strong opioids (for > 3 months per year) for the management of CNCP over a two-year period were retrospectively analysed. Factors including type of opioid, indications for opioid prescription, uncontrolled side effects, functional status, coexisting psychological issues and suspicion of aberrant drug-seeking behaviour were studied.
RESULTS Out of the 1,389 new patients who visited the centre, 42 (3.0%) with CNCP received strong opioids for more than three months a year. The most commonly prescribed opioid was methadone (42.9%). The principal diagnosis for opioid prescription was spinal pain (38.1%). Ten patients had severe side effects. 15 patients saw improvement in activities of daily living scores. Although ten patients returned to work, one stopped following the commencement of opioids. Aberrancy was seen in 5 (11.9%) patients, while 19 (45.2%) had psychological issues and 10 (23.8%) required psychiatric co-management.
CONCLUSION Opioids are not a panacea for chronic pain. Therefore, functional outcomes should be considered more important end points than mere reductions in pain scores. A multidisciplinary team approach is essential for the effective management of patients with CNCP who are on opioids.
Keywords: Asia, chronic pain, non-cancer pain, opioids, Singapore
Singapore Med J 2013; 54(9): 506-510; http://dx.doi.org/10.11622/smedj.2013173
|1. Turk DC, Okifuji A. Pain terms and taxonomies. In: Fishman SM, Ballantyne JC, Rathmell JP, eds. Bonica's management of pain, 4th ed. Philadelphia: Lippincott Williams & Wilkins, 2010:13-4.|
|2. Phillips CJ, Harper C. The economics associated with persistent pain. Curr Opin Support Palliat Care 2011; 5:127-30.
|3. Reid KJ, Harker J, Bala MM, et al. Epidemiology of chronic non-cancer pain in Europe: narrative review of prevalence, pain treatments and pain impact. Curr Med Res Opin 2011; 27:449-62.
|4. Colson J, Koyyalagunta D, Falco FJ, Manchikanti L. A systematic review of observational studies on the effectiveness of opioid therapy for cancer pain. Pain Physician 2011; 14:E85-102.|
|5. Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Systemically administered analgesic drugs. In: Macintyre PE, Scott DA, Schug SA, eds. Acute pain management: the scientific evidence, 3rd ed. Melbourne: ANZCA, 2010: 57-64.|
|6. Paulozzi LJ , Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf 2006; 15:618-27.
|7. Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010; 152:85-92.
|8. Kuehn BM. Opioid prescriptions soar: increase in legitimate use as well as abuse. JAMA 2007; 297:249-51.
|9. Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med 2006; 31:506-11.
|10. The British Pain Society. Opioids for persistent pain: Good practice 2010. London: the British Pain Society, 2010: 36.|
|11. Furlan AD, Reardon R, Weppler C; National Opioid Use Guideline Group. Opioids for chronic noncancer pain: a new Canadian practice guideline. CMAJ 2010; 182:923-30.
|12. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain 2009; 10:113-30.
|13. Manchikanti L, Ailinani H, Koyyalagunta D, et al. A systematic review of randomized trials of long-term opioid management for chronic non-cancer pain. Pain Physician 2011;14:91-121.|
|14. Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain 2009; 10:147-59.
|15. Yeo SN, Tay KH. Pain Prevalence in Singapore. Ann Acad Med Singapore 2009; 38:937-42.|
|16. Covinsky K. Aging, arthritis, and disability. Arthritis Rheum 2006; 55:175-6.
|17. Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence and predictors. Clin J Pain 1997; 13:150-5.
|18. Caudill-Slosberg MA, Schwartz LM, Woloshin S. Office visits and analgesic prescriptions for musculoskeletal pain in US: 1980 vs. 2000. Pain 2004; 109:514-9.
|19. Sørensen HT, Rasmussen HH, Møller-Petersen JF, et al. Epidemiology of pain requiring strong analgesics outside hospital in a geographically defined population in Denmark. Dan Med Bull 1992; 39:464-7.|
|20. Bell JR. Australian trends in opioid prescribing for non-cancer pain, 1986-1996. Med J Aust 1997; 167:26-9.|
|21. Reid MC, Engles-Horton LL, Weber MB, et al. Use of Opioid Medications for Chronic Noncancer Pain Syndromes in Primary Care. J Gen Intern Med 2002; 17:173-9.
|22. Adams NJ, Plane MJ, Fleming MF, et al. Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage 2001; 22:791-6.
|23. Rosti G, Gatti A, Costantini A, Sabato AF, Zucco F. Opioid-related bowel dysfunction: prevalence and identification of predictive factors in a large sample of Italian patients on chronic treatment. Eur Rev Med Pharmacol Sci 2010; 14:1045-50.|
|24. Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain: an epidemiological study. Pain 2006; 125:172-9.
|25. Clark MR, Galati SA. Opioids and psychological issues: A practical, patient-centered approach to a risk evaluation and mitigation strategy. Eur J Pain Suppl 2010; 4:261-7.
|26. Dersh J, Polatin PB, Gatchel RJ. Chronic pain and psychopathology: research findings and theoretical considerations. Psychosom Med 2002; 64:773-86.
|27. Larance B, Ambekar A, Azim T, et al. The availability, diversion and injection of pharmaceutical opioids in South Asia. Drug Alcohol Rev 2011; 30:246-54.
|28. Højsted J, Sjøgren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain 2007; 11:490-518.
|29. Boscarino JA, Rukstalis MR, Hoffman SN, et al. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis 2011; 30:185-94.
|30. Peppin JF, Passik SD, Couto JE, et al. Recommendations for urine drug monitoring as a component of opioid therapy in the treatment of chronic pain. Pain Med 2012; 13:886-96.
|31. Schonwald G. What is the role of Urine Drug Testing (UDT) in the management of chronic non-cancer pain with opioids? Pain Med 2012;13:853-6.
|32. Yee SK. What you need to know: guidelines to medical practitioners for proper maintenance of drugs and dispensing records (including controlled drugs). Singapore Med J 1998; 39:520-2.|
|33. AGC Singapore. Misuse of Drugs Act 2008. Chapter 185 [online]. Available at: statutes.agc.gov.sg. Accessed February 4, 2013.|
|34. British Pain Society. GfK NOP Pain Survey 2005. London: the British Pain Society publications, 2005.|
|35. Johannes CB, Le TK, Zhou X, Johnston JA, Dworkin RH. The prevalence of chronic pain in United States adults: results of an Internet-based survey. J Pain 2010; 11:1230-9.
|36. Lin JJ, Alfandre D, Moore C. Physician attitudes toward opioid prescribing for patients with persistent noncancer pain. Clin J Pain 2007; 23:799-803.
|37. Spitz A, Moore AA, Papaleontiou M, et al. Primary care providers' perspective on prescribing opioids to older adults with chronic non-cancer pain: a qualitative study. BMC Geriatr 2011; 11:35.