Strategies for Managing Tolerance in the Pain Patient

A lively Q&A session took place after a pro and con debate on the use of opioids during the “Essential Tools for Treating the Patient in Pain” series on Wednesday, February 3 at the American Academy of Pain Medicine’s annual meeting.

Attendees didn’t seem too concerned with the pro and con aspect of the presentation and immediately started in on tolerance and how to deal with it.

Here’s the relevant information that was drawn from the conversations observed:

What are the most effective means of dealing with tolerance?

Slowly backing patients down from high opioid levels.

Though it can take, in some cases, 12 months or more, one presenter finds that when he is finally able to reduce his patients’ opioid levels by 50-80%, their pain levels “drop like a shot.” This same presenter conducted a small study to confirm his findings and found that patient pain levels were reduced between 40-50% for an average of 44 months.

The presenters also didn’t seem to be sold on opioid-induced hyperalgesia. They agreed that it was an interesting theoretical model that is well-demonstrated in animal models, but they were not sure that disease progression wasn’t the true culprit underlying the increased sensitivity. They recommend ruling this out before immediately turning to opioids or an increase in opioid dosage.

Is tolerance less likely when using short-acting medicine?

The presenters believe that this is not likely because of their formulation, and in fact, short-acting medications in severe-to-moderate pain pose a separate set of problems because of peaks and valleys, which one presenter likened to an initiation of a mini-withdrawal.

They backed up this assertion by citing a 2002 study lead by Christine Miaskowski, RN, PhD, FAAN, Associate Dean, Dept. of Physiological Nursing UCSF School of Nursing. After examining pain in two groups of bone cancer patients (one on an around-the-clock medication regimen, the other on an as-needed basis) the researchers found “no significant differences in average, least, or worst pain intensity scores or number of hours per day in pain between the 2 groups,” but also noted that the around-the-clock group was prescribed five times more medication than the as-needed group and used twelves times as much.

The question of short-acting medications and tolerance actually spurred a side debate…a debate within a debate…how meta…

While one presenter said that he prescribes short-acting medication during the day and long-acting drugs at night, another countered that his goal is a single pill approach, meaning that he ultimately tries to give a patient the largest pill at the appropriate dosage level. He believes that this also helps doctors avoid “getting burned” with a negative opioid experience.

This approach, another presenter said, is not feasible because there are just no pills or patches built for a 24-hour period of care and countered that some patients just regularly need a second dose in the afternoon and that that doesn’t indicate a failure of the medication but how that particular patient’s pain operates.

Despite disagreeing on the methods, the presenters agreed that the overall goal is function and that if a patient is not self-weaning from short-acting analgesics before the first refill, then a physician’s perspective about the patient and their pain should begin to change.