Conventional practice for medical conditions for chronic opioid therapy.

When considering chronic opioid therapy (COT) for chronic noncancer pain, it has been proposed that it is prudent to contemplate 4 questions which may be useful and influence medical decision making (1): 1. What is the conventional practice? 2. Are there reasonable alternatives to COT? 3. What is the risk of adverse events? 4. Is the patient likely to be a responsible drug-taker? Question 4 – (Is the patient likely to be a responsible drug-taker?) has received a lot of attention as well as a number of articles in the literature, including multiple tools designed to help clinicians “predict” whether an individual patient is likely to be a responsible drug-taker (2-6). Clinicians attempting to predict which patients may have a higher risk of exhibiting aberrant drug-related behavior on COT may be aided by: ORT (7), SOAPP-R (8), DIRE (9), DAST (10), SISAP (11), and clinical interview (12,13), especially with significant self-reports of craving for opioid medications (14). As far as following a patient’s adherence to the care plan, urine drug screening may be invaluable (15-19).Overall, opioids have been demonstrated to have some degree of efficacy for noncancer painful states (20-23). However, it seems that there is a relative scarcity of literature addressing the first question (e.g., what painful noncancer medical conditions are considered better suited for chronic opioid therapy and what painful noncancer medical conditions are considered less well-suited for chronic opioid therapy). This distinction may hold particular clinical significance, since definite methods exist that allow clinicians to predict which patients might be more likely to respond to opioids. Baseline pain intensity does not predict the outcome after an appropriate opioid titration (24). Kalso and colleagues (25) found no clear pattern of baseline pain (type or severity) or patient characteristics emerged that could be used to predict responders before the start of opioid treatment. However, a one month trial period appears sufficient to determine response and tolerability in most cases (25). Eisenberg and colleagues’ (26) study used both static and dynamic quantitative sensory testing (QST) on 40 healthy volunteers in order to test whether this methodology can predict the analgesic effects of oral oxycodone, as compared to a placebo, on latency to onset, pain intensity, and tolerance to the cold pressor test (CPT). The static QST results showed that heat pain thresholds predicted the magnitude of reduction in pain intensity in response to oxycodone treatment [F(1,22) = 5.63, P = 0.027, R(2)=0.17] (26). The dynamic QST results showed that temporal summation (TS) predicted the effect of oxycodone on the tolerance to CPT [F(1,38) = 9.11, P = 0.005, R(2) = 0.17 (26). These results suggest that both static and dynamic QST have the potential to be useful in the prediction of the response to opioid treatment (26). In an attempt to help primary care prescribers determine if their opioid prescribing habits were “usual”/average or a bit out of range of average (beyond 2 standard deviations of the mean opioid dose), --Passik and Kirsh (27) published a schematic meant to help primary care physicians with From: Albany Medical College, Albany, NY;