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Prescription Treatment Strategies for Opiate Medications with Chronic Pain

Naliboff BD, Wu SM, Schieffer B, Pham Q, Baria A, Van Vort W, Davis F, Bolus R, Shekelle P. Prescription Treatment Strategies for Opiate Medications with Chronic Pain. Paper presented at: VA HSR&D National Meeting; 2007 Feb 22; Arlington, VA.


Objectives: While opiate medications clearly provide short term pain relief, their use in chronic pain has remained controversial due to questions of long term efficacy, addiction potential, and proper prescribing guidelines. Objectives: To examine pain relief and abuse behaviors over a 1 year prospective trial of opiate treatment for chronic pain, and determine differential outcomes from two different treatment strategies: 1) a Tolerable Pain (TP) strategy in which patients were maintained on steady dosages of opiate medications, and 2) an Adequate Relief (AR) strategy in which opiate medications were increased in response to reports of inadequate pain relief. Methods: 135 Veterans (mean age = 52.52, SD = 7.47) who were deemed eligible for long-term opiate medication treatment were randomized into one of the treatment arms and followed monthly for 12 months. Opiate prescriptions were given according to treatment group specific guidelines. Outcomes included self-reported pain severity and relief and substance abuse (clinician rated behaviors and discharge due to substance misuse). Linear mixed effects modeling was used for the primary analyses. Results: No group differences were found in clinician ratings of medication misuse or discharge (overall 29.20% discharged due to misuse). There was a significant treatment group x month interaction (p < 0.01) for medication dosage with the AR group increasing in dose over the year (19.52 mg morphine equivalents difference at month 12). All pain outcomes showed significant declines (improvements) over the study (all ps < 0.01). Ratings of worst pain and ‘amount of relief after taking medications’ also showed a significant group x month interaction (p < 0.05) resulting from the AR group having greater declines in worst pain and greater relief compared to the TP group over the study period. Implications: This study provides evidence for a significant rate of opiate abuse even in selected patients closely followed for chronic pain. Overall there was a small improvement in some pain related outcomes with no increased risk for medication abuse for patients treated according to a well monitored AR compared to a TP guideline. Impacts: This study’s findings should lead to better provision of long-term opiate treatment for chronic pain through careful patient selection, appropriate guidelines, and close clinical monitoring.

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