Magazine article Clinical Psychiatry News

Opioids Still Worthwhile despite Street-Drug Taint

Magazine article Clinical Psychiatry News

Opioids Still Worthwhile despite Street-Drug Taint

Article excerpt

ATLANTA -- Long-acting opioids, such as oxycodone, have received a bad rap in recent months from several mainstream press reports of their misuse as street drugs. But for patients with pain from peripheral neuropathy, or other chronic pain, they're an essential last resort.

"There's a lot of concern about the use of these products, but I think it's important to recognize that these are also very useful products, and we're hearing only one side of the story. We're not hearing about the literally millions of patients who have benefited from the long-acting opioids," said Dr. Sidney H. Schnoll, referring to recent accounts in the New York Times and Time magazine of the drugs being crushed to remove their time-release coating and then snorted or injected to produce a high similar to that of heroin.

Pain from peripheral neuropathy is best managed with a combination of agents, starting first with antiseizure medications, adding older-generation antidepressants, and then ramping up with opioids, Dr. Schnoll said at the annual meeting of the American College of Physicians-- American Society of Internal Medicine.

But with any of these medications, the key is pushing the dosage until there's an analgesic effect or until there are side effects, a treatment approach that may be hampered by the latest public scrutiny of opioids.

In addition, even when the optimal dosage is identified, there may be alterations that require changes to once again reach an optimal effect, he said.

That may sound simple, but in everyday practice, fear of prescribing too much of a controlled agent results in patients never truly achieving a therapeutic effect and then lapsing into what's known as a pseudoaddiction.

On the other hand, it's important to emphasize to patients that they are probably never going to be 100% pain free. "If you can increase function and get the pain down to a level that they can tolerate, you've done a lot," said Dr. Schnoll, who chairs the division of substance abuse medicine at Virginia Commonwealth University, Richmond.

He offered these tips regarding specific medications for peripheral neuropathy:

* Antiseizure agents. Gabapentin is the most thoroughly studied antiepileptic medication for neuropathic pain, and "the data are very clear that you have to go up to a rather substantial dose," to as much as 4-5 g daily, to get adequate relief. In addition, the patient has to build up to that dose rather slowly, which can take a lot of time because the initial dose is only about 100 mg. Most side effects occur when the drug is titrated up too quickly.

* Antidepressants. The tricyclic antidepressant amitriptyline has the most data supporting its use for neuropathic pain; newer antidepressants such as selective serotonin reuptake inhibitors have not been shown to be effective.

Several studies show that amitriptyline is effective for some people in doses as low as 10 mg. "However, if you don't get an effect at that level, you really need to drive up the dose," he said.

* Opioids. Of the three basic classes of opioids, only the amount of pure mu agonists, such as morphine, should be pushed until there are side effects shown.

Mixed agonists have a ceiling effect, which in many patients can cause a marked dysphoric response. …

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