Positioning Opioids in the Chronic Pain Treatment Algorithm

Although opioids should not be used as first-line therapies for chronic pain, they still need to be positioned somewhere in the treatment algorithm for patients who have failed all other modalities, moderator Jeffrey A. Gudin, MD, notes.

When the time comes to choose an opioid formulation for a chronic pain patient, Christopher Gharibo, MD, says he considers prior successes and failures in response to therapy and side effects, as well as the day-to-day timeline of the pain.

“For the vast majority of us that have treated nonmalignant pain, the pain is constant and daily. For that, I like to emphasize a trend away from the quick-acting or short-acting medications because, for that ongoing daily pain, you really need to provide an extended-release medication,” Gharibo explains. “Just like we don’t treat hypertension every 4 hours (and) we don’t treat diabetes every 4 hours, we shouldn’t treat constant, daily pain every 4 hours.”

Expanding on the importance of looking at daily patterns of pain, Gharibo points out that “osteoarthritic pain, spinal stenosis, and osteoarthritis (OA) of the knees will be worse in the morning and pretty much build up as the day goes on, so somebody like that could be at a higher dose in the morning and a lower dose at night, whereas somebody with postherpetic neuralgia pain may be on a higher dose at night and a lower dose during the day.”

For that reason, Gudin and Vitaly Gordin, MD, have both cut back on immediately switching new chronic pain patients taking short-acting opioid tablets to a long-acting analgesic. Rather, Gordin says he starts new patients on a baseline, long-acting medication supplemented with a short-acting agent, adjusting the dose over time.