Implications of opioid analgesia for medically complicated patients.
Opioid analgesics have an established role in the management of postoperative pain and cancer pain, and are gaining acceptance for the management of moderate to severe chronic noncancer pain, most notably chronic low back pain and osteoarthritis, that does not respond to other interventions. Many patients with chronic pain have co-morbid medical conditions that may complicate opioid therapy. Selecting the appropriate opioid requires knowledge of how individual opioids differ with respect to metabolism and interaction with concurrent medications, as well as the reasons why specific medical conditions may influence their efficacy and tolerability. Polypharmacy is a common complicating condition in the elderly and in patients with psychiatric illness, cancer, cardiovascular disease, diabetes mellitus or other chronic illnesses. Polypharmacy, though often necessary for patients with multiple medical conditions, also multiplies the risk of drug interactions. Pharmacokinetic drug interactions can increase or reduce exposure to the opioid or concurrent medications, reducing efficacy and/or tolerability and increasing toxicity. Pharmacodynamic interactions can enhance the depressive effects of opioids, compromising safety. Patients with impaired renal or hepatic function may have difficulty clearing or metabolizing opioids and concurrent medications, leading to increased risk of adverse events. Patients with cardiovascular, cerebrovascular or respiratory disease (including smokers of >/=2 packs/day with no other diagnosis) may be more susceptible to respiratory depression, bradycardia and hypotension with any opioid, and a few specific opioids pose additional risks. Patients with cerebrovascular disease, dementia, brain injury or psychiatric illness are more susceptible to opioid effects on the CNS, which can include euphoria, cognitive impairment and sedation. Appropriate opioid selection may mitigate these effects. Even in older patients, addiction, abuse and misdirection of prescribed opioids are of concern. Higher risk exists for patients with psychiatric illness, history of substance abuse, and identifiable substance abuse risk factors. Screening for abuse potential and vigilant patient monitoring should be routine. Opioids differ in their ability to produce euphoria, based on opioid receptor agonism, but substance abusers may be more influenced by availability, familiarity and cost factors. Consequently, opioid selection has limited influence on abuse potential but can facilitate ease of monitoring. This review provides an overview of opioid use in medically complicated patients and recommendations on how to optimize analgesia while avoiding adverse events and drug interactions in the clinical setting. Articles cited in this review were identified via a search of EMBASE and PubMed. Articles selected for inclusion discussed characteristics of specific opioids and general physiological aspects of opioid therapy in important patient populations.
Smith
Howard
H
Department of Anesthesiology, Albany Medical College, Albany, New York, USA.
Bruckenthal
Patricia
P
D000701:Analgesics, Opioid / Q000008:administration & dosage / Q000009:adverse effects* / Q000627:therapeutic use*; D004333:Drug Administration Routes; D006801:Humans; D001523:Mental Disorders; D010146:Pain / Q000150:complications* / Q000188:drug therapy*; D019338:Polypharmacy; D019966:Substance-Related Disorders / Q000209:etiology
D000701:Analgesics, Opioid
Prim Care Companion J Clin Psychiatry. 2008;10(5):415-6
19158987
J Gerontol A Biol Sci Med Sci. 2003 Jan;58(1):76-81
12560416
J Pain Symptom Manage. 2008 Sep;36(3):280-8
18619768
Pain. 2007 Jun;129(3):355-362
17449178
Osteoarthritis Cartilage. 2008 Feb;16(2):137-62
18279766
Postgrad Med J. 2001 Nov;77(913):703-7
11677279
JAMA. 2000 Apr 5;283(13):1710-4
10755497
J Pharmacol Exp Ther. 2007 Oct;323(1):265-76
17656655
Br J Anaesth. 1982 Dec;54(12):1267-70
7171414
J Pain Palliat Care Pharmacother. 2004;18(4):17-30
15760805
Reg Anesth Pain Med. 2004 May-Jun;29(3):237-42
15138910
Drug Alcohol Depend. 2007 Apr;88 Suppl 1:S71-84
17227697
J Pain Symptom Manage. 2005 Jul;30(1):96-103
16043013
Postgrad Med. 2009 Jul;121(4):91-102
19641275
Anesthesiology. 2009 Sep;111(3):625-31
19672166
Can Fam Physician. 2009 Jan;55(1):68-9, 69.e1-5
19155373
Clin Pharmacokinet. 2007;46(10):825-50
17854233
Cancer. 2002 Mar 15;94(6):1836-53
11920548
Circulation. 2007 Mar 27;115(12):1634-42
17325246
J Clin Pharm Ther. 2008 Apr;33(2):101-8
18315774
Anesthesiology. 1997 Apr;86(4):995-1004
9105246
Am J Geriatr Pharmacother. 2007 Dec;5(4):345-51
18179993
Heart. 2007 Sep;93(9):1051-5
17344330
Clin Pharmacokinet. 2007;46(11):965-80
17922561
J Pain Symptom Manage. 2006 May;31(5):465-76
16716877
Anesthesiology. 2005 May;102(5):1014-22
15851890
Pain Med. 2008 May-Jun;9(4):425-32
18489633
J Pain. 2005 Oct;6(10):662-72
16202959
Chest. 2007 Sep;132(3 Suppl):368S-403S
17873181
Cephalalgia. 2006 Feb;26(2):89-97
16426261
J Clin Pharm Ther. 2007 Apr;32(2):199-202
17381671
Anesthesiology. 2001 May;94(5):824-32
11388534
J Am Geriatr Soc. 1985 Apr;33(4):278-85
3989190
J Pain Symptom Manage. 1996 Apr;11(4):203-17
8869456
Anesthesiology. 2000 May;92(5):1473-6
10781294
Anesth Analg. 1996 Mar;82(3):600-6
8623968
Anesthesiology. 1960 Jul-Aug;21:397-400
13798620
Dtsch Med Wochenschr. 1999 Jul 30;124(30):896-8
10464491
Anesth Analg. 2008 Aug;107(2):494-506
18633028
J Pain Symptom Manage. 2002 Feb;23(2):107-13
11844630
Br J Clin Pharmacol. 1992 Jul;34(1):53-9
1633068
Neuromodulation. 2007 Oct;10(4):300-28
22150890
Anesth Analg. 2006 Apr;102(4):1255-66
16551934
Anesthesiology. 1996 May;84(5):1243-57
8624021
Mayo Clin Proc. 2009 Jul;84(7):613-24
19567715
Aliment Pharmacol Ther. 2008 May;27(9):798-809
18266997
Eur J Clin Pharmacol. 1988;34(4):353-7
3402521
J Opioid Manag. 2008 May-Jun;4(3):131-44
18717508
J Clin Pharmacol. 2005 Mar;45(3):337-45
15703368
J Pain Palliat Care Pharmacother. 2007;21(1):63-6
17430835
J Clin Sleep Med. 2007 Aug 15;3(5):455-61
17803007
J Pain. 2009 Feb;10(2):113-30
19187889
J Psychiatr Pract. 2005 Jan;11(1):5-15
15650617
Prog Neuropsychopharmacol Biol Psychiatry. 2006 Sep 30;30(7):1356-8
16631290
Clin Pediatr (Phila). 1997 Mar;36(3):171-3
9078419
Pain Physician. 2008 Mar;11(2 Suppl):S5-S62
18443640
Pain. 1992 Apr;49(1):87-91
1375728
Psychosom Med. 2005 Jan-Feb;67(1):1-8
15673617
Clin Pharmacokinet. 1999 Jul;37(1):17-40
10451781
Crit Care Med. 1999 Feb;27(2):407-11
10075068
Oncology (Williston Park). 2000 Nov;14(11A):135-50
11195407
Clin Pharmacokinet. 1999 Jun;36(6):439-52
10427468
Drug Metab Dispos. 1997 Jan;25(1):1-4
9010622
Anesthesiology. 1987 Mar;66(3):327-31
3826690
Clin J Pain. 2008 Jul-Aug;24(6):528-35
18574362
World J Gastroenterol. 2003 Feb;9(2):359-63
12532467
Emerg Med J. 2008 Apr;25(4):205-9
18356349
Ann Intern Med. 2007 Oct 2;147(7):478-91
17909209
Expert Opin Investig Drugs. 2009 Mar;18(3):255-63
19243277
Pain. 2007 Dec 5;132(3):289-300
17467904
Am J Ther. 2006 Nov-Dec;13(6):534-42
17122535
Ther Drug Monit. 2007 Dec;29(6):687-710
18043468
Proc West Pharmacol Soc. 2001;44:83-4
11794005
Pain Pract. 2007 Dec;7(4):352-6
17986163
J Pain Symptom Manage. 1991 Apr;6(3):125-8
2016556
Pain Pract. 2008 Jul-Aug;8(4):287-313
18503626
Am Fam Physician. 2006 Sep 1;74(5):756-62
16970019
Pain. 2008 Sep 15;138(3):507-513
18342447
Am J Ther. 2008 Mar-Apr;15(2):157-66
18356636
J Clin Anesth. 1997 Nov;9(7):582-5
9347436
J Am Geriatr Soc. 2009 Aug;57(8):1331-46
19573219
Pain Manag Nurs. 2004 Jun;5(2):75-93
15297954
Pain. 1993 Mar;52(3):331-339
8460051
Drugs Aging. 2003;20(5):347-60
12696995
Arch Intern Med. 2007 Dec 10;167(22):2469-75
18071169
Pain Physician. 2006 Jul;9(3):215-25
16886030
Nephrol Dial Transplant. 1999 Apr;14(4):903-9
10328468
J Pharmacol Exp Ther. 1999 May;289(2):1169-75
10215701
J Pain Symptom Manage. 2004 Nov;28(5):497-504
15504625
Pain Med. 2009 May-Jun;10(4):654-62
19302436
Br J Anaesth. 1989 Jan;62(1):28-32
2644963
Am J Forensic Med Pathol. 1992 Mar;13(1):42-3
1585886
Drugs Aging. 2008;25(4):343-55
18361544
Arch Intern Med. 2003 Dec 8-22;163(22):2716-24
14662625
J Gerontol. 1976 Mar;31(2):155-63
1249404
Br J Clin Pharmacol. 1990 Mar;29(3):289-97
2310653
Pain Med. 2009 Mar;10(2):319-26
19207240
Pain. 2004 Dec;112(3):372-380
15561393
J Pain Symptom Manage. 2004 Mar;27(3):260-7
15010104
Clin Pharmacol Ther. 2003 Aug;74(2):102-12
12891220
Am J Psychiatry. 2003 May;160(5):890-5
12727692
Ann Pharmacother. 2007 Jul;41(7):1144-52
17595308
Drug Metab Lett. 2008 Jan;2(1):67-75
19356073
J Neurophysiol. 2003 Sep;90(3):1581-8
12761284
J Pain Palliat Care Pharmacother. 2007;21(2):5-16
17844723
Circulation. 2007 Feb 6;115(5):e69-171
17194875
Pain. 2005 Dec 15;119(1-3):95-103
16298066
Hepatology. 1989 Feb;9(2):297-301
2643548
Clin Pharmacol Ther. 1998 Dec;64(6):603-11
9871425
Clin Geriatr Med. 2008 May;24(2):263-74, vi
18387455
J Pain Symptom Manage. 1995 Apr;10(3):184-6
7543126
Emerg Med J. 2009 Mar;26(3):230-1
19234030
Br J Psychiatry. 2005 Sep;187:243-7
16135861
Am Fam Physician. 2001 Nov 15;64(10):1735-40
11759080
Pain Physician. 2008 Mar;11(2 Suppl):S89-S104
18443642
Cardiovasc Res. 1999 Dec;44(3):568-78
10690289
Am J Kidney Dis. 2000 Jan;35(1):146-9
10620557
Pain Med. 2005 Mar-Apr;6(2):107-12
15773874
Drug Alcohol Depend. 2010 Apr 1;108(1-2):110-4
20074867
Clin Exp Pharmacol Physiol. 2000 Jul;27(7):524-8
10874511
Clin Pharmacol Ther. 1981 Sep;30(3):353-62
7273599
J Clin Pharm Ther. 2007 Apr;32(2):169-75
17381667
Eur J Clin Pharmacol. 1989;36(5):501-6
2753069
Support Care Cancer. 2006 Jan;14(1):56-64
15952009
Anesthesiology. 2004 Jun;100(6):1573-81
15166580
Clin Pharmacol Ther. 1988 Jan;43(1):63-71
3335120