Often, she said, physicians caring for patients with chronic pain or severe acute pain tend to have their own internal "point of comfort" dose thresholds with short-acting opioids, and when that dose of a single agent does not adequately control pain, they layer on additional medications -- also in lower than effective doses.

"So whenever [physicians] reach that comfortable maximum dose they -- go on to a different opioid," she explained. That may result in a patchwork approach to treatment involving a few oral opioids and fentanyl patches, for example, which still does not provide adequate control but rather primarily only ensures that the physician does not get outside her or his dose comfort zone.

She cited a case in which a physician who was concerned about opioid dosing had a patient on a T6 schedule, which was not only cumbersome but ultimately ineffective.

When palliative care physicians come on to the scene, they're typically saddled with sorting out the problems, Dr. Abrahm said, and then convincing the care team to use a combination of a long- and a short-acting opioid, along with adjuvant drugs as needed. That more aggressive approach, provided opioid-induced complications have been recognized and addressed, often results in better control.

But it's important to tease out the reasons the ineffective dosing and medication choices were occurring rather than taking the punitive "why in the world do you have this patient on seven different medications?" stance. The latter, Dr. Abrahm said, can make the ensuing conversation less productive-- and possibly lose the "teachable-moment" opportunity. Rather, the palliative care specialist who proceeds more gently might learn that the prescribing physician is uncomfortable with prescribing a fentanyl patch in a higher than 100 mcg dose, for example, or more than 200 mg of morphine.

During her presentation, Dr. Abrahm also pointed to several other strategies that might reduce barriers to effective pain treatment, including, among others:

· Identifying possible barriers to opioid absorption -- oral or transdermal. "Sometimes, you just have to assume that the fentanyl patch isn't working," she said.
· Helping patients make the distinction between pain and anxiety, and then treating each separately and appropriately.
· Ensuring that breakthrough-pain doses are high enough to stop the pain crisis.
· Understanding and accepting that opioids can work well and may even be preferable to other analgesics when treating patients with a history of substance use disorders.
· Encouraging patients to complete pain diaries, to identify when and where exacerbations or pain spikes occur.

She also cautioned that although an aggressive, preemptive approach is needed to prevent the constipation associated with opioids, certain lactose-containing agents might cause gas or cramping in certain patients, thus increasing their discomfort.

The session was supported through an educational grant from Cephalon, Inc.


[Presentation title: Dispelling Misconceptions and Psychosocial Impediments to Opioid Use: Barriers to Effective Pain Management]

Copyright © 2009 P\S\L Consulting Group Inc. All rights reserved. Republication or redistribution of P\S\L content is expressly prohibited without the prior written consent of P\S\L. P\S\L shall not be liable for any errors, omissions or delays in this content or any other content on its sites, newsletters or other publications, nor for any decisions or actions taken in reliance on such content.