Opioids for the Treatment of Pain: The Risk of Treating a Multivariate Symptom

The use of opioids has a long cultural and societal history and has played a unique role in advancing both medicine and the treatment of pain. Over the last two decades or so, prescribers have compromised the role of opioids in the treatment of pain to such an extent that it has become a national crisis. Each year, opioids have been causing a record number of deaths and negatively affecting those individuals’ quality of life because of dependence. In many clinical situations, the use of an opioid is necessary for proper patient care, despite the potential risk of dependence that is now of national concern.1 That risk is best assessed and mitigated by clinicians who have a comprehensive understanding of the clinical pharmacology of opioids and possess the skills and willingness to properly assess an individual’s pain relief needs by considering alternative medications and painmanagement treatments and/or strategies. The American College of Clinical Pharmacology (ACCP) has previously published a policy statement on the treatment of opioid addiction.2 However, the choice of an opioid is the second step in the clinical process. This policy statement addresses the first step in the clinician’s rationale for choosing an analgesic, especially the appropriateness of an opioid, for the treatment and/or management of pain. It is the clinician who can properly assesses the patient’s pain, whether anticipated by a medical procedure or presented as pain the patient is experiencing without visible tissue damage, along with its length of time that precedes the choice of an analgesic. Pain is a multidimensional experience encompassing a number of physiological systems mediated by neuronal tracks subserved by various neurotransmitters. Pain is composed of affective, cognitive, motivational, and discriminative components. It is this complexity that can confound its treatment, allowing it to respond to a number of different classes of medications. Pain is defined by the International Association for the Study of Pain (IASP; www.IASP-pain.org) as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.” The definition incorporates the multiple components. The appropriate clinical use of opioids requires an assessment of the patient that often exceeds simply writing the prescription. The one necessary component to accomplish this assessment is often the least available, and that is timewith the patient.3 In view of the decreased personal interaction between clinician and patient in contemporary medical practice, one unfortunate result is the inadvertent prescribing of more potent medications than may actually be required to compensate for the difference. It may be partly out of convenience to the prescriber to write a prescription for an excess of opioids to avoid the patient’s returning to complain of unrelieved pain. An unintended consequence for the provider may be in patient reviews that may further complicate the prescribing judgment of the prescriber.4 Pain is a complex symptom, and the line between acute and chronic pain is not always distinct. There are many physiological differences between acute and chronic pain, but the principal difference is that chronic pain involves the central nervous system through input of the autonomic nervous system. This also allows for the many different drug classes to be considered in its treatment and management. Acute pain, or pain that is induced in a controlled manner such as a surgical procedure, can be managed more easily than pain resulting from a chronic condition. Prescribing opioids for acute pain requiring a central component allows the treatment to have a beneficial effect in reducing patient anxiety and promoting restful sleep. Short-term opioid therapy may be appropriate for bouts of acute pain, particularly if the surgery results in a large amount of tissue damage. It is sound practice to have the patient