Post by Denise on Sept 5, 2012 9:07:25 GMT
From Medscape Medical News: Conference News
'Perils Outweigh Promise' in Chronic Opioid Experience?
Kate Johnson
August 31, 2012 (Milan, Italy) — In driving the dramatic rise in opiate therapy worldwide, the United States "has conducted an experiment in population-wide treatment of chronic noncancer pain," showing that the promise of this treatment remains "largely unfulfilled," while the perils "are now well demonstrated," one expert says.
Mark Sullivan, MD, PhD, professor of psychiatry and behavioral sciences and adjunct professor of bioethics and humanities at the University of Washington, in Seattle, discussed the challenges of opioid use here during the International Association for the Study of Pain 14th World Congress on Pain.
According to the Centers for Disease Control and Prevention, US sales of opioid therapy have quadrupled in the past decade, with a recipient cohort "enriched by high-risk regimens and high-risk patients," said Dr. Sullivan.
Although treatment guidelines recommend chronic opioid therapy "for patients with intractable pain and no history of substance abuse" and "careful use in people with mental health disorders," in fact, these are the patients most likely to get opioid therapy, said Dr. Sullivan — a phenomenon he has termed "adverse selection."
"Unfortunately, patients with substance abuse and mental health disorders are also more likely to receive higher opioid doses and higher potency regimens, as well as concurrent sedative-hypnotic medications, largely because patients with chronic pain also have insomnia," he said — a trend that this group has shown increases the risk for long-term, aberrant use ( J Adolesc Health. 2012;50:553-558).
Another study by Dr. Sullivan and colleagues has shown that patients with depression and mental health disorders are 3 to 4 times more likely to receive opioids, and that patients with alcohol and nonopioid abuse are 4 to 5 times more likely and those with opioid abuse or dependence are 5 to 10 times more likely to be prescribed opioid therapy (Clin J Pain. 2010;26:1-8).
The quadrupling of US opiate sales in the past decade has been mirrored by parallel rises in overdose death and treatment rates for addiction, said Dr. Sullivan.
Now, 15,000 accidental overdose deaths are reported in the United States each year — which exceeds the annual rate of motor vehicle deaths across 30 states combined — largely in white, middle-aged, rural, poor men (MMWR. 2011;60:1-6). In addition, in 2009, 500,000 emergency department visits were associated with misuse, he said.
Although "the classic peril has been iatrogenic addiction," it is now clear that the perils of opiate therapy extend beyond this and other medical risks, he said.
"Now we're seeing there's actually a much broader sense of negative consequences. In the US, we're also seeing 'social iatrogenesis,' where we're getting escalated drug diversion, abuse, and overdose in adolescents and poor, rural, middle-aged adults, and also 'cultural iatrogenesis,' which is an erosion of our ability to handle pain in nonmedical ways, along with perhaps unrealistic expectations of relief."
Although the medical community focuses on the promise of opioid therapy in terms of pain relief, this mechanism is inextricably linked to opioid's additional relief of social and cultural pain, said Dr. Sullivan.
Some of the lure of opioid therapy is its potential to reduce the stress of social separation, he explained. Sensitivity to social and physical pain increases and decreases in concert — affecting the same areas of the brain.
"Opioids reduce the stress of social separation and impact maternal/infant bonding. If you don't have an intact opioid system, the very basic primary original social bond between mother and infant doesn't form — that's how crucial opioids are for social functioning."
Because of this interconnection between physical and psychosocial pain relief, Dr. Sullivan said, "We shouldn't think more renewed efforts and careful selection are going to solve this problem. I think that opioids have these diverse functions, and it's not possible on our part to focus just on physical pain — I don't think any effort to contain opioids in that way is really going to work."
We have already tried the 'careful selection' recommended in all treatment guidelines and it doesn't work, because patients self-select into the therapy by their distress level. The patients who feel the greatest need for the therapy will find a way to obtain it.
Elaborating in an e-mail to Medscape, Dr. Sullivan explained, "We have already tried the 'careful selection' recommended in all treatment guidelines and it doesn't work, because patients self-select into the therapy by their distress level. The patients who feel the greatest need for the therapy will find a way to obtain it.
"We should try to identify high-risk patients and follow them more closely," he added. "But we also need to recognize the risks of the medication regimens and be especially careful to not use high doses and concurrent sedative-hypnotics."
With the United States currently responsible for roughly 80% of worldwide opiate use, Dr. Sullivan advised the international medical community that it may be "useful to frame the US experience as an experiment for worldwide consumption."
Not Many Tools
"As a basic scientist, I was struck by his conclusion that finally we don't know about benefits, but we know for sure about adverse effects — that is pretty negative," Brigitte L. Kieffer, PhD, told Medscape Medical News.
Dr. Kieffer, from the Institut de Génétique et de Biologie Moléculaire et Cellulaire, in Illkirch, France, delivered the paired plenary session that preceded Dr. Sullivan's presentation, looking at what is currently known about the structure and function of opioid receptors.
She said the benefits of opioid therapy for acute pain relief are undisputed but agreed that with currently available opioid therapies, clinicians will not be successful in separating pain relief from reward, because abuse liability always remains with morphine-type compounds targeting the mu opioid receptor.
"Clinicians are very limited, they have a limited number of drugs, and all the drugs they have act at the mu receptor. There's no really new opiate on the market that would target delta receptors, for example," she noted.
"And, all in all, mu receptors are expressed in both pain pathways and reward pathways in the brain — they will necessarily act on both responses," Dr. Kieffer concluded. "You can maybe play with mode of administration, maybe discover more biased drugs for the mu receptor, but [there are] not many tools."
Neither speaker has disclosed any relevant financial relationships.
International Association for the Study of Pain 14th World Congress on Pain. Plenary session PL 05, PL 04. Presented August 29, 201
'Perils Outweigh Promise' in Chronic Opioid Experience?
Kate Johnson
August 31, 2012 (Milan, Italy) — In driving the dramatic rise in opiate therapy worldwide, the United States "has conducted an experiment in population-wide treatment of chronic noncancer pain," showing that the promise of this treatment remains "largely unfulfilled," while the perils "are now well demonstrated," one expert says.
Mark Sullivan, MD, PhD, professor of psychiatry and behavioral sciences and adjunct professor of bioethics and humanities at the University of Washington, in Seattle, discussed the challenges of opioid use here during the International Association for the Study of Pain 14th World Congress on Pain.
According to the Centers for Disease Control and Prevention, US sales of opioid therapy have quadrupled in the past decade, with a recipient cohort "enriched by high-risk regimens and high-risk patients," said Dr. Sullivan.
Although treatment guidelines recommend chronic opioid therapy "for patients with intractable pain and no history of substance abuse" and "careful use in people with mental health disorders," in fact, these are the patients most likely to get opioid therapy, said Dr. Sullivan — a phenomenon he has termed "adverse selection."
"Unfortunately, patients with substance abuse and mental health disorders are also more likely to receive higher opioid doses and higher potency regimens, as well as concurrent sedative-hypnotic medications, largely because patients with chronic pain also have insomnia," he said — a trend that this group has shown increases the risk for long-term, aberrant use ( J Adolesc Health. 2012;50:553-558).
Another study by Dr. Sullivan and colleagues has shown that patients with depression and mental health disorders are 3 to 4 times more likely to receive opioids, and that patients with alcohol and nonopioid abuse are 4 to 5 times more likely and those with opioid abuse or dependence are 5 to 10 times more likely to be prescribed opioid therapy (Clin J Pain. 2010;26:1-8).
The quadrupling of US opiate sales in the past decade has been mirrored by parallel rises in overdose death and treatment rates for addiction, said Dr. Sullivan.
Now, 15,000 accidental overdose deaths are reported in the United States each year — which exceeds the annual rate of motor vehicle deaths across 30 states combined — largely in white, middle-aged, rural, poor men (MMWR. 2011;60:1-6). In addition, in 2009, 500,000 emergency department visits were associated with misuse, he said.
Although "the classic peril has been iatrogenic addiction," it is now clear that the perils of opiate therapy extend beyond this and other medical risks, he said.
"Now we're seeing there's actually a much broader sense of negative consequences. In the US, we're also seeing 'social iatrogenesis,' where we're getting escalated drug diversion, abuse, and overdose in adolescents and poor, rural, middle-aged adults, and also 'cultural iatrogenesis,' which is an erosion of our ability to handle pain in nonmedical ways, along with perhaps unrealistic expectations of relief."
Although the medical community focuses on the promise of opioid therapy in terms of pain relief, this mechanism is inextricably linked to opioid's additional relief of social and cultural pain, said Dr. Sullivan.
Some of the lure of opioid therapy is its potential to reduce the stress of social separation, he explained. Sensitivity to social and physical pain increases and decreases in concert — affecting the same areas of the brain.
"Opioids reduce the stress of social separation and impact maternal/infant bonding. If you don't have an intact opioid system, the very basic primary original social bond between mother and infant doesn't form — that's how crucial opioids are for social functioning."
Because of this interconnection between physical and psychosocial pain relief, Dr. Sullivan said, "We shouldn't think more renewed efforts and careful selection are going to solve this problem. I think that opioids have these diverse functions, and it's not possible on our part to focus just on physical pain — I don't think any effort to contain opioids in that way is really going to work."
We have already tried the 'careful selection' recommended in all treatment guidelines and it doesn't work, because patients self-select into the therapy by their distress level. The patients who feel the greatest need for the therapy will find a way to obtain it.
Elaborating in an e-mail to Medscape, Dr. Sullivan explained, "We have already tried the 'careful selection' recommended in all treatment guidelines and it doesn't work, because patients self-select into the therapy by their distress level. The patients who feel the greatest need for the therapy will find a way to obtain it.
"We should try to identify high-risk patients and follow them more closely," he added. "But we also need to recognize the risks of the medication regimens and be especially careful to not use high doses and concurrent sedative-hypnotics."
With the United States currently responsible for roughly 80% of worldwide opiate use, Dr. Sullivan advised the international medical community that it may be "useful to frame the US experience as an experiment for worldwide consumption."
Not Many Tools
"As a basic scientist, I was struck by his conclusion that finally we don't know about benefits, but we know for sure about adverse effects — that is pretty negative," Brigitte L. Kieffer, PhD, told Medscape Medical News.
Dr. Kieffer, from the Institut de Génétique et de Biologie Moléculaire et Cellulaire, in Illkirch, France, delivered the paired plenary session that preceded Dr. Sullivan's presentation, looking at what is currently known about the structure and function of opioid receptors.
She said the benefits of opioid therapy for acute pain relief are undisputed but agreed that with currently available opioid therapies, clinicians will not be successful in separating pain relief from reward, because abuse liability always remains with morphine-type compounds targeting the mu opioid receptor.
"Clinicians are very limited, they have a limited number of drugs, and all the drugs they have act at the mu receptor. There's no really new opiate on the market that would target delta receptors, for example," she noted.
"And, all in all, mu receptors are expressed in both pain pathways and reward pathways in the brain — they will necessarily act on both responses," Dr. Kieffer concluded. "You can maybe play with mode of administration, maybe discover more biased drugs for the mu receptor, but [there are] not many tools."
Neither speaker has disclosed any relevant financial relationships.
International Association for the Study of Pain 14th World Congress on Pain. Plenary session PL 05, PL 04. Presented August 29, 201