Adverse effects and cognitive function among primary care patients taking opioids for chronic nonmalignant pain

Randall T. Brown, MD, Megan Zuelsdorff, BS, Michael Fleming, MD, MPH

Abstract


Chronic opioid therapy is commonly prescribed for chronic nonmalignant pain. Few published data describe the adverse effects experienced by patients with chronic nonmalignant pain being treated by primary care physicians. A prevalence study was conducted on a sample of 1,009 patients (889 receiving chronic opioids) being treated by 235 primary care physicians. Standardized questionnaires and medical record reviews were used to assess rates of addiction, pain diagnosis and severity, opioid adverse effects, and mental health. The mean daily dose of opioids was 92 mg using a morphine-equivalent conversion. Side effects included constipation (40 percent), sleeping problems (25 percent), loss of appetite (23 percent), and sexual dysfunction (18 percent), with patients on daily opioids experiencing more side effects than subjects on intermittent medication. The Medical Outcomes Study Mental Health Inventory (MOS-MHI) cognitive functioning scale indicated poorer cognitive function in the overall sample of chronic pain patients as compared to a general clinical sample (Δ x 95 percent CI = 9.28, 13.76). However, there were limited differences in MOS scores between chronic pain subjects on daily opioids vs. intermittent opioids vs. no prescription opioids. A regression model suggests that psychological measures and pain severity are more predictive of decrements in cognitive function than specific opioid preparations or daily opioid dose. Physicians should closely monitor patients for adverse effects and adequacy of pain control when using chronic opioid therapy for chronic pain treatment. Psychological health, an important predictor of cognitive dysfunction, is a particularly important measure to actively monitor and manage.

Keywords


opioids, adverse effects, chronic nonmalignant pain, primary care physicians

Full Text:

PDF

References


Brookoff D: Chronic pain: A new disease? Hosp Pract (Hosp Ed). 2000; 7: 1-18.

Christo PJ: Opioid effectiveness and side effects in chronic pain. Anes Clin North Am. 2003; 21 (December): 699-713.

Collett BJ: Chronic opioid therapy for non-cancer pain. Br J Anaesth. 2001; 87 (July): 133-143.

Evans P: Opioids for chronic musculoskeletal pain. In: Kalso E, McQuay H, Wiesenfeld-Hallin Z (eds.): Opioid Sensitivity of Chronic Non-Cancer Pain: IASP Press, 1999.

Graven S, De Vet H, van Kleefe M, et al.: Opioids in chronic non-malignant pain: A criteria based review of the literature. Paper presented at: Ninth World Congress on Pain, Progress in Pain Research and Management, 2000.

Marcus DA: Treatment of nonmalignant chronic pain. Am Fam Physician. 2000; 61: 1331-1338.

McCarberg BH, Barkin RL: Long-acting opioids for chronic pain: Pharmacotherapeutic opportunities to enhance compliance, quality of life, and analgesia. Am J Ther. 2001; 8 (May-June): 181-186.

Bannwarth B: Risk-benefit assessment of opioids in chronic noncancer pain. Drug Saf. 1999; 21 (October): 283-296.

Coniam S: Prescribing opioids for chronic pain in non-malignant disease. Paper presented at the Edinburgh Symposium on Pain Control and Medical Education, London, 1989.

Potter M, Schafer S, Gonzalez-Mendez E, et al.: Opioids for chronic nonmalignant pain. Attitudes and practices of primary care physicians in the UCSF/Stanford Collaborative Research Network. University of California, San Francisco. J Fam Pract. 2001; 50: 145-151.

Reid MC, Engles-Horton LL, Weber MB, et al.: Use of opioid medications for chronic noncancer pain syndromes in primary care. J Gen Intern Med. 2002; 17: 173-179.

Reisine T, Pasternak G: Opioid analgesics and antagonists. In: Hardman J, Limbird L (eds.): Goodman & Gilman’s The Pharmacologic Basis of Therapeutics, 9th ed. New York: McGraw-Hill, 1996.

Bruera E, Macmillan K, Hanson J, et al.: The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain. 1989; 39: 13-16.

Sjogren P, Olsen AK, Thomsen AB, et al.: Neuropsychological performance in cancer patients: The role of oral opioids, pain and performance status. Pain. 2000; 86: 237-245.

Sjogren P, Thomsen AB, Olsen AK: Impaired neuropsychological performance in chronic nonmalignant pain patients receiving long-term oral opioid therapy. J Pain Symptom Manage. 2000; 19: 100-108.

Byas-Smith MG, Chapman SL, Reed B, et al.: The effect of opioids on driving and psychomotor performance in patients with chronic pain. Clin J Pain. 2005; 21: 345-352.

Cumming RG: Epidemiology of medication-related falls and fractures in the elderly. Drugs Aging. 1998; 12: 43-53.

Shorr RI, Griffin MR, Daugherty JR, et al.: Opioid analgesics and the risk of hip fracture in the elderly: Codeine and propoxyphene. J Gerontol. 1992; 47: M111-M115.

Vainio A, Ollila J, Matikainen E, et al.: Driving ability in cancer patients receiving long-term morphine analgesia. Lancet. 1995; 346: 667-670.

Arkinstall W, Sandler A, Goughnour B, et al.: Efficacy of controlled-release codeine in chronic non-malignant pain: A randomized, placebo-controlled clinical trial. Pain. 1995; 62: 169-178.

Dhaliwal HS, Sloan P, Arkinstall WW, et al.: Randomized evaluation of controlled-release codeine and placebo in chronic cancer pain. J Pain Symptom Manage. 1995; 10: 612-623.

Peloso PM, Bellamy N, Bensen W, et al.: Double blind randomized placebo control trial of controlled release codeine in the treatment of osteoarthritis of the hip or knee. J Rheumatol. 2000; 27: 764-771.

Peloso PM, Fortin L, Beaulieu A, et al.: Analgesic efficacy and safety of tramadol/acetaminophen combination tablets (Ultracet) in treatment of chronic low back pain: A multicenter, outpatient, randomized, double blind, placebo controlled trial.[see comment]. J Rheumatol. 2004; 31: 2454-2463.

Fleming MF, Mundt MP, Balousek S, et al.: Chronic pain, addiction and opioids in a primary care sample; Submitted to JAMA. September 2005.

Stewart A, Ware J, Sherbourne C, et al.: Psychological distress/ well-being and cognitive functioning measures. In: Stewart A, Ware J (eds.): Measuring Functioning and Well-Being: The Medical Outcomes Study Approach. Durham, NC: Duke University Free Press, 1992.

Miele GM, Carpenter KM, Cockerham MS, et al.: Substance Dependence Severity Scale: Reliability and validity for ICD-10 substance use disorders. Addict Behav. 2001; 26: 603-612.

Miele GM, Carpenter KM, Smith Cockerham M, et al.: Concurrent and predictive validity of the Substance Dependence Severity Scale (SDSS). Drug Alcohol Depend. 2000; 59: 77-88.

Miele GM, Carpenter KM, Smith Cockerham M, et al.: Substance Dependence Severity Scale (SDSS): Reliability and validity of a clinician-administered interview for DSM-IV substance use disorders. Drug Alcohol Depend. 2000; 59: 63-75.

Leonhard C, Mulvey K, Gastfriend D, et al.: The Addiction Severity Index: A field study of internal consistency and validity. J Subst Abuse Treat. 2000; 18: 129-135.

McLellan AT, Kushner H, Metzger D, et al.: The Fifth Edition of the Addiction Severity Index. Journal of Substance Abuse Treatment. 1992; 9: 199-213.

Ross CE, Mirowsky J: Neighborhood disadvantage, disorder, and health. J Health Soc Behav. 2001; 42: 258-276.

Adams NJ, Plane MB, Fleming MF, et al.: Opioids and the treatment of chronic pain in a primary care sample. J Pain Symptom Manage. 2001; 22: 791-796.

Rabkin JG, Markowitz JS, Ocepek-Welikson K, et al.: General versus systematic inquiry about emergent clinical events with SAFTEE: implications for clinical research.[see comment]. J Clin Psychopharmacol. 1992; 12: 3-10.

Jacobson AF, Goldstein BJ, Dominguez RA, et al.: Interrater agreement and reliability measures of SAFTEE: General inquiry vs. systematic inquiry. Psychopharmacol Bull. 1987; 23: 97-101.

Guy W, Wilson WH, Brooking B, et al.: Intra-interrater reliability of SAFTEE using videotape interviews and clinical trial data. Psychopharmacol Bull. 1987; 23: 93-96.

Markowitz JS, Rabkin JG, Stewart J, et al.: Validity assessment of SAFTEE: A preliminary report. Psychopharmacol Bull. 1987; 23: 102-105.

Guy W, Wilson WH, Brooking B, et al.: Reliability and validity of SAFTEE: Preliminar analyses. Psychopharmacol Bull. 1986; 22: 397-401.

Rabkin JG, Markowitz JS: Side effect assessment with SAFTEE: Pilot study of the instrument. Psychopharmacol Bull. 1986; 22: 389-396.

Jacobson AF, Goldstein BJ, Dominguez RA, et al.: Interrater agreement and intraclass reliability measures of SAFTEE in psychopharmacologic clinical trials. Psychopharmacol Bull. 1986; 22: 382-388.

Levine J, Schooler NR: SAFTEE: A technique for the systematic assessment of side effects in clinical trials. Psychopharmacol Bull. 1986; 22: 343-381.

American Pain Society: Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 4th ed. Glenview, IL, 1999.

Dahl J: Personal communication. 2005.

Fleming M: Personal communication. 2005.

Krause C: Personal communication. 2005.

Foley KM, Houde RW: Methadone in cancer pain management: Individualize dose and titrate to effect. [comment]. J Clin Oncol. 1998; 16: 3213-3215.

Pereira J, Lawlor P, Vigano A, et al.: Equianalgesic dose ratios for opioids. A critical review and proposals for long-term dosing. J Pain Symptom Manage. 2001; 22: 672-687.

American Pain Society: Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain, 5th ed. Glenview, IL, 2003.

Bruera E, Belzile M, Pituskin E, et al.: Randomized, doubleblind, cross-over trial comparing safety and efficacy of oral controlled-release oxycodone with controlled-release morphine in patients with cancer pain.[see comment]. J Clin Oncol. 1998; 16: 3222-3229.

Watanabe S, Pereira J, Hanson J, et al.: Fentanyl by continuous subcutaneous infusion for the management of cancer pain: A retrospective study. J Pain Symptom Manage. 1998; 16: 323-326.

Bruera E, Pereira J, Watanabe S, et al.: Opioid rotation in patients with cancer pain. A retrospective comparison of dose ratios between methadone, hydromorphone, and morphine. Cancer. 1996; 78: 852-857.

Ballenger J: Benzodiazepines. In Schatzberg A, Nemeroff C (eds.): The American Psychiatric Press Textbook of Psychopharmacology, 2nd Edition. Washington DC: American Psychiatric Press, 1998.

Charney D, Mihic J, Harris R: Hypnotics and Sedatives. In Hardman J, Limbird L (eds.): Goodman & Gilman’s The Pharmacological Basis of Therapeutics, 10th ed. New York: McGraw-Hill, 2001.

Bodie J, Lewis J, Schow D, et al.: Laboratory evaluations of erectile dysfunction: An evidence based approach. J Urol. 2003; 169: 2262-2264.

Johnson A, III, Jarow J: Is routine endocrine testing of impotent men necessary? J Urol. 1992; 147: 1542.

Lue TF. Male sexual dysfunction—how little do we know? J Urol. 2003; 169: 2265.




DOI: https://doi.org/10.5055/jom.2006.0023

Refbacks

  • There are currently no refbacks.