Narcotics for chronic pain and migraine – pro

Close up of a Medical History form and a doctor's Stethoscope

Chronic non-cancer pain has become a significant public health problem in the the USA. It is being more and more recognized that well meaning physicians and medical groups and the state worker compensation systems have brought about serious untoward and unexpected consequences by providing opioids for chronic pain. Chronic opioid use usually does not effectively control such pain and has brought with it a host of problems; including hyperalgesia, diversion and abuse, overdoses and a host of ancillary problems. Some 100 million individuals are on chronic opioids in the USA and 34.000.00 young adults die every years from opioids that they obtained from the medical cabinets of relatives or friends who are taking long term opioids for non-cancer pain. The medical profession and the responsible governmental and professional bodies have began to issue calls for a major change in the pattern of care for chronic pain and for a more responsible approach to the chronic pain opioid epidemic.

Short acting potent opioids, such as Percocet, and ultrashort acting narcotics, like Actiq are particularly hard to justify for the management of chronic pain, because they only act for a short period of pain on a pain that is of longer duration. Short-acting narcotics often are used for the acute treatment of migraine headache that is moderate to severe in intensity. Orally self-administered narcotics that are commonly prescribed include codeine (typically prescribed with acetaminophen; eg, Tylenol #3), hydrocodone (typically prescribed with acetaminophen; eg, Lortab, Vicodin), meperdine (eg, Demerol), and oxycodone (either alone – eg, Oxy IR– or with acetaminophen – eg, Percocet). More potent short-acting narcotics include hydromorphone (Dilaudid) and morphine.

Self-administered short-acting narcotics also are available in an intranasal formulation (butyrophenone: Stadol) and a “lollipop” (hydromorphone: Actiq). Intranasal Stadol is notoriously addictive, and patients who are naive to narcotic therapy typically experience bothersome side effects with its use (even including hallucinations and delusional thinking).

All of the short-acting narcotics have the potential for promoting physical dependence, psychological addiction, or both. These drugs are meant for intermittent or short-term use, and – along with the dependence/addiction potential – extended use tends to lead rapidly to tolerance (ie, higher and higher doses of the opioid are required to produce an ever diminishing clinical response).

There is a potential role for migraines for ultrashort acting narcotics  – to abort an incipient attack. However, it is tricky to find the right moment to intervene and, if treated too early, repeated doses would be required, with all the ill effects that it would entail.

Andrea M. Trescot, MD, Standiford Helm, MD, Hans Hansen, MD, Ramsin Benyamin, MD, Scott E. Glaser, MD, Rajive Adlaka, MD, Samir Patel, DO, and Laxmaiah Manchikanti, MD Opioids in the Management of Chronic Non-Cancer Pain: An Update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines Opioids in the Management of Chronic Non-Cancer Pain: An Update of American Society of the Interventional Pain Physicians’ (ASIPP) Guidelines Pain Physician 2008: Opioids Special Issue: 11:S5-S62 • ISSN 1533-3159

For Lay version see here

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