Continued from Page 1

But the Ladder, originally designed to guide physicians in treating malignant pain, is not as foolproof with pain that is nonmalignant in origin. Using strong opioid combinations for pain that continues for months or years can be challenging for providers, and long-term opioid use for the treatment of chronic pain is aggressively being studied.² Although addiction potential is extremely rare (<1% overall), newer research suggests long-term opioid treatment actually may increase pain over time through a process described as pro-nociception at specific pain receptors.³

In the interim, opioid use has represented the mainstay for patients experiencing significant pain. Dose adjustment may ultimately be necessary for patients with chronic nonmalignant pain, as opioids have no ceiling dose, and raised doses of medication may be required to achieve an analgesic effect. Alternatively, opioid rotation, a process of switching the patient from one opioid to an opioid from another family of drugs, can be successful in treating refractory pain.

The use of adjunctive medications (see box) also presents an important option for treating chronic pain. Adjunct medications have been used alone or in combination with opioids and have proved successful in alleviating pain via either approach.

A recent article in the Journal of the American Medical Association,² for example, investigated the efficacy of opioid use vs. alternate therapy for the treatment of chronic pain — with somewhat surprising findings. Although patients experienced an equitable analgesic effect whether they were treated with opioids or adjuncts alone, the “treatment factor” found to be most important in the outcome of the patient was engagement with a single physician and not the analgesic prescribed.

These results, along with those of similar studies, have encouraged researchers and physicians to believe nonopioid therapy may hold promise for the future.

More help available

Newer treatment options for chronic nonmalignant pain include combinations of drugs that work synergistically to relieve symptoms. Finding the appropriate mix of adjuvant therapies is often a game of trial and error. As pain continues, it may be the caregiver who has the difficult job of persuading the patient to try yet another medication. Patients suffering from chronic nonmalignant pain may have invested hundreds of dollars in unsuccessful analgesic options to use at home. It may be difficult to persuade these patients to add another medication to their daily regimen or to adjust the dose of an existing medication.

Topical medications, such as the Lidoderm patch, have proved particularly effective for patients with neuropathic pain. Originally created for patients suffering from postherpetic pain, these patches may be cut to appropriate size and left in place for about 12 to 18 hours — a particularly convenient benefit for patients who experience pain overnight. Cutting the patches to size may save patients additional expense and assist in reducing trips to the pharmacy.