Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.PerspectiveSafe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
The purpose of this article is to elaborate on barriers to research participation by older adults at end of life. We focus on the hospice setting and classify barriers to research participation into six domains: societal attitudes toward death, research procedures, health care organizations, agency staff, patients' families and caregivers, and patient characteristics. We characterize particular participation issues, uncertainties in participation for individuals with advanced illness, and infringements on patient self-determination, as well as potential solutions to these research challenges. Our observation of the complex palliative context includes the realization that a singular change will not have large enough impact on participation. We conclude that, along with the responsibility to expand the research base addressing the needs of dying individuals, there is also a need to understand the challenges of implementing research projects with older adults at end of life.
Editors note: A reply to this letter by Dr. Bruce Ferrell, Chairman of the AGS Panel on Chronic Pain in Older Persons, follows. In reply: The letter by Dr. King emphasizes several controversial issues articulated briefly in the guidelines.1 The epidemiology of addiction among patients taking opioids for medical indications is not well described in the geriatric population. Data are often biased in sample and uncontrolled for many confounding variables. Authors do not agree on definitions of dependency and addiction. Whereas physiologic dependence is common, psychological dependence and addictive behaviors are more difficult to evaluate and are often confused with behavior of normal patients seeking effective treatment in an atmosphere of drug regulation and patient distrust. The AGS Panel on Chronic Pain in Older Persons recognized that opioid addiction does occur and the Panel emphasized that opioid analgesic medications should not be prescribed indiscriminately. However, the Panel concluded that fear of addiction and other side-effects do not justify failure to provide effective pain relief in older patients, especially those near the end of life. In fact, the Panel suggested that opioid analgesic medications are probably not prescribed often enough and often represent a better choice than other available drugs for many older patients with chronic pain. There is a growing basic science literature that suggests opioid drugs may have an effect on the immune system. The effects are often nonspecific, indirect, and not entirely understood. The Panel did not deal with this issue because correlation with clinical epidemiology remains unclear, and age-related implications of these laboratory findings remain speculative. The vast majority of evidence-based literature surrounds the use of antidepressants for the treatment of neuropathic pain. When used for other types of pain, reported benefits are inconsistent among several studies, and the effect size is often reported to be small or moderate at best. In contrast, studies of antidepressants used for neuropathic pain have shown more consistent results and generally higher response rates. Thus, the Panel concluded that although other patients may benefit, most nonopioid analgesic (adjuvant) drugs seem to work best for neuropathic pain. It is also important for clinicians to know that none of these drugs are specifically approved by the FDA for pain indications. Although results of the NIH Consensus Conference on Acupuncture were not available at the time of the AGS Panel's meetings, results of that conference should be important to clinicians. The NIH Consensus Panel on Acupuncture concluded that the incidence of adverse effects from acupuncture was substantially lower than that of many drugs or other accepted medical procedures for many conditions. They found sufficient evidence to conclude that acupuncture is efficacious for postoperative dental pain. Their report states, “There are reasonable studies (although sometimes only single studies) showing relief of pain with acupuncture on diverse pain conditions such as menstrual cramps, tennis elbow, and fibromyalgia.” However, the NIH consensus panel concluded, “Although many other conditions may have received some attention in the literature and, in fact, the research suggests some exciting potential areas for the use of acupuncture, the quality or quantity of the research evidence is not sufficient to provide firm evidence of efficacy at this time.”2 Dr. King's point regarding the classification of psychologically based pain disorders is well taken. Psychologically based pain disorders are classified as a specific type of somatoform disorder distinct from conversion reactions, hypochondriasis, and other somatoform disorders.3 The term‘psychogenic pain,’ i.e., pain reports for which no identifiable pathology can be found other than psychologically based mechanisms, is an older term that may be pejorative, suggesting that these patients’ complaints are somehow different from other pain complaints. The AGS Panel's intention was to focus on the fact that patients with purely psychological conditions may benefit from specific psychiatric interventions, but analgesic medications and other medical procedures for pain are usually of little benefit.
Hippocrates. Aristotle. Edgar Allan Poe. Henry Beecher. As author Dr. Haider Warraich points out, what these luminaries of science, philosophy, literature, and medicine had in common was an uncommon interest in the definition of death, or more aptly, when and how death actually occurred. These many years later, we still don’t know the answer to these profound questions. This is the central theme elaborated by Warraich, a physician-in-training just starting his career in cardiology. His writing has a compelling narrative style, à la House of God meets Being Mortal meets Sapiens, A Brief History of Humankind.Warraich weaves stories from his experiences as a medical resident in a busy urban intensive care unit (ICU) into an interesting admixture of biology lesson, history of medicine, social commentary, medical ethics review, and evolving policies and politics about dying in America. As he attempts to demystify dying and death (a brave but quixotic effort), he succeeds at illuminating how fear of death has positively influenced medical progress, resulting in a predictably longer life span for most people. Conversely, he points out in graphic detail—with images that rekindle the countless soul-wrenching experiences and memories of most physicians-in-training—how technology has influenced medicine, oftentimes driving physicians, patients, and their loved ones alike to counterproductive, harmful prolongation of dying.The essential pivot-point of Western medicine’s decision-making revolves around the tenet to “do no harm.” This becomes the unspoken subtext of the book, implicitly challenging the reader to confront the construct of “harm” within the context of modern medical practice, wherein almost every death in the ICU, at least, is choreographed around withdrawal of some form of life support. And even though the use of hospice in the United States has increased over the last several years, the majority of those who receive this form of palliative care are referred very late in the game, leaving behind both exhausted caregivers and depleted bank accounts. Challenging life prolongation at any cost as the apotheosis of modern medicine, his message is a thinly disguised plea to revisit and reinfuse relationship and compassion as the core elements of care.Why should anesthesiologists read this book? If for no other reason, here is an internist who appreciates the value of our specialty, as evoked in an opening passage of the book: “My attending, an anesthesiologist with Jedi-master skills, stood by me….” Beyond that poetic, metaphorical bit of interprofessional flattery is the inescapable reality that has shaped our field since its origins in resuscitation, critical care, and pain relief. Whether in the emergency department, the operating room, the ICU, or the hospice, anesthesiologists have skills that can immeasurably improve life or merely salvage it. This book may not have all the answers, but it stimulates all the right questions in all 13 chapters of highly relatable prose.Warraich begins by providing a crisp review of cellular demise at the most elemental level. This is the most didactic portion of the book, but it is made relevant by interspersed tales from the bedside. He captures the essence of the living–dying continuum in relationship to health versus disease at the biologic level in his pithily worded statement, “…the only thing worse than a cell that forgets how to live—is one that refuses to die.”From that starting point, he moves on to a sprint through history, highlighting the annals of medical and public health–related innovations that have led to our most recent epoch of relatively long average life expectancy. Chapter 3 (“Where Death Lives Now”) will be of particular interest to anesthesiologists as it recalls the inception and evolution of cardiopulmonary resuscitation. This is the point that he introduces the continually running theme of medical ethics, religious views, and social mores into the equation. He starts this thread by recounting the seminal case of Karen Ann Quinlan and reminding us of the notable 1957 address by Pope Pius XII to a group of anesthesiologists. In that meeting, the Pope clarified that physicians had no duty to prolong medical treatment in the face of no hope of recovery against a patient’s wishes.From that point on, the author proceeds to outline difficult and often heart-wrenching cases, elucidating the absence of a bright line dividing living and dying in the rapidly growing, aging population with chronic progressive illnesses, or the ever-evolving definitions of brain death. The chapters “How Death Was Redefined” and “When the Heart Stops” rekindled memories of the challenging and highly practical polemic embodied by the question “when is dead really dead?” exemplified by issues brought to the fore in Anesthesiology by Gail Van Norman.1Subsequent chapters take a more sociological and theological turn, exploring the role of societal views as they pertain to the experience of dying and death. This theme is encapsulated in the statement “Modern medicine has done much to stave off death but little to ameliorate peoples’ fear of dying.” He proceeds to probe, question, and thoughtfully challenge the culture of modern health care, averring that that “…physicians have critical conversations with individuals without any knowledge of their spiritual fingerprints.”The final chapters focus on the social and economic impact of systematic “death denial.” Although this line of often-contentious discourse has become pervasive in medical and political circles of late (as witnessed by the rapid rise in “aid in dying” legislative activity around the country), Warraich approaches these issues both critically and with a degree of sensitivity that is more helpfully thought-provoking than off-putting or divisive. He leaves the reader on an uplifting note, providing some hope that the hallmark of dying for so many—the desperate loneliness of debilitating illness—might find reprieve in the connectedness that modern communication technology (e.g., social media; telemedicine) might provide.In conclusion, I found this book to be interesting, thought-provoking, highly relevant, and informative to contemporary anesthesiology while also being entertaining. In my experience, this combination is rare in medically oriented books.
Objective. A panel of experts in pain medicine and public policy convened to examine root causes and risk factors for opioid-related poisoning deaths and to propose recommendations to reduce death rates.
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