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Opioids Effective Against Neuropathic Pain

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    Opioids Effective Against Neuropathic Pain

    This story came out thislast march but I think that it is worthwhile looking at again.

    Opioids Effective Against Neuropathic Pain

    By Amanda Gardner
    HealthDay Reporter

    WEDNESDAY, March 26 (HealthDayNews) -- Opioid medications, long stigmatized by patients and physicians alike, may now be poised for greater acceptance in the field of pain management.

    A study appearing in the March 27 issue of The New England Journal of Medicine found that higher doses of the morphine-like medication levorphanol reduced neuropathic pain significantly more than lower doses of the same medicine.

    A second study, this one appearing in the March 25 issue of Neurology, found that another opioid, OxyContin, decreased pain and improved sleep quality for people with diabetic neuropathy.

    Neuropathic pain emanates from injury to the central or peripheral nerves and affects more than 2 million Americans. There are no clear guidelines on how to treat the condition, and many available drugs have had disappointing results, writes Dr. Kathleen M. Foley in an editorial accompanying The New England Journal of Medicine study.

    Three broad categories of drugs are available to treat neuropathic pain, explains Dr. Russell K. Portenoy, lead author of the Neurology article and chairman of the department of pain medicine and palliative care at Beth Israel Medical Center in New York City. They are opioids, non-opioids and adjuvant analgesics, which are drugs that are for something else (for example, local anesthetics and antidepressants) but have been shown to work against pain.

    Among those three groups, opioids have been the most controversial. "The positioning of opioid therapy for patients for chronic pain of all types, not just neuropathic, is evolving very quickly," Portenoy says. "Fifteen years ago, opioids were considered to be inappropriate for most patients with chronic pain. Now, in 2003, we have consensus statements from many medical societies that say opioids should be considered."

    One reason for opioids' position on the margins of medicine is, of course, their association with addiction. They are classified as narcotics and are regulated by the Drug Enforcement Administration, which in itself is enough to make some doctors squeamish. There have also been issues regarding side effects and a perception that patients would develop a tolerance to the drugs, causing them to be ineffective, Portenoy says.

    Another reason is that about a decade ago, some studies indicated that opioids were ineffective against nerve pain. "That controversy stood in contrast to a lot of clinical observation," Portenoy says.

    Fast forward to 2003 and The New England Journal of Medicine article. In this study, 81 adults with neuropathic pain were randomly assigned to receive either high-strength (0.75 milligrams) or low-strength (0.15 milligrams) capsules of levorphanol for eight weeks.

    The study authors picked the lesser known drug levorphanol over high-profile drugs such as methadone or morphine precisely because they wanted to bypass as much as possible any preconceived notions. Although the consent form clearly stated this was an opioid, the researchers felt levorphanol didn't have the same stigma.

    Participants could regulate their own doses within certain limits so as to achieve the best balance between pain relief and side effects.

    The high-strength capsules reduced pain by 36 percent, whereas the low-strength dosage reduced pain by 21 percent. These results are comparable to the effects of tricyclic antidepressants and the anticonvulsant gabapentin, both of which are commonly used to treat pain.

    On average, patients in the high-strength group took 11.9 capsules per day while patients in the low-strength group took 18.3 a day, which was close to the 21-a-day upper limit allowed. Functioning and sleep were improved in both groups. And even though the trial lasted only eight weeks, participants did not seem more likely to escalate their dose by the end of the study, indicating that they were not developing a tolerance to the drug.

    "Our study shows that [the drugs] clearly are effective," says study author Dr. Michael Rowbotham, a professor of clinical neurology and anesthesia at the University of California, San Francisco, and director of the school's Pain Clinical Research Center. "The higher-dose levels were more effective at relieving pain than the lower-dose levels, but it carried a price in terms of side effects."

    Before the study ended, 59 patients (27 percent) withdrew, mostly because of various side effects, and more people dropped out in the high-dose group. The side effects of irritability and personality changes occurred only in the higher-strength arm of the study.

    Certain types of pain disorders were also easier to treat than others. Only three out of 10 patients with brain injury-related pain (such as stroke) were able to complete the study. Individuals with pain from spinal cord injury or multiple sclerosis seemed to benefit greatly from the high-dose capsules.

    Even though the drug didn't help everyone, it helped enough to earn it a place in the arsenal of pain medications, the authors state.

    "The fundamental thing that was shown in these studies is that opioids can work for neuropathic pain. You can get adequate pain relief and you can do that without intolerable toxicities," Portenoy reports. "All of these controlled trials are creating a very strong evidence base that is refuting the perspective that neuropathic pain is unresponsive to opioids. It's very reasonable for doctors to now think about trying opioids."

    More information

    For more on the use of opioids in pain management, visit the American Pain Society or the American Academy of Pain Medicine.

    (SOURCES: Russell K. Portenoy, M.D., chairman, department of pain medicine and palliative care, Beth Israel Medical Center, New York City; Michael Rowbotham, M.D., professor, clinical neurology and anesthesia, University of California, San Francisco, and director, UCSF Pain Clinical Research Center; March 27, 2003, The New England Journal of Medicine)

    Copyright © 2003 ScoutNews, LLC. All rights reserved.

    Opioids and Neuropathic Pain

    This is a very tough question and can only be answered by the patient. Always trade-offs and always a crap shoot. My concerns, which may not be relevant to anyone else, are:

    1) I come from a family with a history of addiction. I couldn't count the number of times my Mom's been in and out of rehab, so I think I have a good chance of becoming one of the minority of people who become addicted versus just having increased tolerance over time.

    2) How likely is it that opioids would be enough to get me back to work? I don't see results that indicate they do enough to do that.

    3) Non-movement is a good way for me to manage my pain to a significant degree. Is it better I should take opioids and be able to, say, stir a brownie mix without increasing my pain, than to not take opioids and just not stir brownie mixes? Or is it better to withstand as much pain as I can while stirring the brownie mix and then sit down and give myself a break?

    4) How likely is it that I would find a doc who would prescribe opioids only to find that doc retires, gets his license yanked, or abandons me because he's decided I'm addicted when the only thing that's happened is my tolerance has gone up? Talk about up the creek without a paddle and I see these stories all the time.

    5) Then, of course, there are the possible side-effects.

    ALL THAT SAID, I have no trouble imagining situations where I would set all the above aside and try opioids.



      are you ssure this is neuropathic pain?.

      i have neuopathic pain, which i have taken the gauntlet of seizure meds for. and there is no choice or alternative to narcotics or other pain meds, luckily ultram works most of the time on top of the other stuff for breakthrough pain,
      its there wether i move or not 24/7 but worse in the evening and at night.
      best to try a good pain mangement , problem is finding good, we know our own bodies better .
      i am ready to try pure opiates and to hell with the seizure meds,

      [This message was edited by yonkersguy on 10-29-03 at 07:21 PM.]
      cauda equina


        I am aware the big boys think opiates work in neuropathic pain, but we keep emphasizing, in PNI, evoked pain from light touch is instantaneous, while in CP, there is a delay of 20-30 seconds or so (Mitchell's delay) which some call slow summation. This delay shows something different is going on in CP than in peripheral neuropathic or PNI.

        Diabetic neuropathy cannot be said to be the equivalent of CP since all those people can still wear clothing. They just have an annoying sunburn feeling. No one is out making friends with Kevorkian, having deep brain implants, or flying to France for motor cortex stimulation or thalamotomy, over diabetic neuropathy. Not to trivialize their suffering, but it hardly fits in with CP. It is more along the lines of athlete's foot. Now I am told in WWII, athlete's foot was considered incapacitating and the GI's were ordered to wear thongs when showering, but CP is many universes of severity beyond diabetic neuropathy.

        Dr. Rowbotham is definitely one of the very best. However, a 36% reduction in pain does not bowl me over. Also, endorphins and opiates are inhibitory in the cord, where peripheral neuropathy originates. But SOME of the opioids all the time (kappa), and ALL the opioids some of the time are EXCITATORY of pain in the brain because of disinhibition, ie inhibiting inhibitory tracts.

        There still exists NO double blinded study I am aware of that shows any benefit for pain of central origin from opiates. When they tried to double blind clonidine, which does help herpetic neuralgia, etc. no benefit at all was shown for CP. This includes CP from cord injured patients. I know some studies imply benefit, but they are NOT double blinded, and I am convinced the benefit is sedation.

        The study mentioned says opiates are comparable to tricyclics (amitryptiline has been double blinded and did show some benefit) but I don't concede much to tricyclics either, since there again, I believe a little pain relief occurs, but mostly sedation. I would not argue with 36% benefit, but that still leaves 64% hell, which is too much.

        I am so grateful to these researchers for even acknowledging we exist, as that is better than most, and for attempting to help, which is even better; but, I am sorry, for severe CP, opiates are like spitting at a forest fire as far as the pain is concerned, although it does sedate us and help the panic.

        The main problem is that if we elect to use opiates over, say, tricyclics, it gets our doctors in trouble with the feds, so we take tricyclics to keep our docs out of trouble. We appreciate them.

        We need to be lumped with PNI to get funding on nerve injury pain, but we must be kept separate when they start talking about basic physiology and about therapy or we make CP patients feel like freaks when the opiate doesn't help us, except to make us drowsy. There may be some exceptions to this, but again, they are the milder cases of CP, who can wear clothing,who can move, eat, and bear a little persistent touch--this actually would take them OUT of Dejerine/Roussy diagnosis of CP, which requires the abnormalities to be called "pain of central origin", as such. Roussy also required that loss of sense of the location of the body surface, unless being touched, be included. Most have this but the terminology is complicated enough they have not stopped to think about it.


          Originally posted by dejerine:

          . Not to trivialize their suffering, but it hardly fits in with CP. It is more along the lines of athlete's foot. Now I am told in WWII, athlete's foot was considered incapacitating and the GI's were ordered to wear thongs when showering, but CP is many universes of severity beyond diabetic neuropathy.
          of disinhibition, ie inhibiting inhibitory tracts.
          i think you mean trench foot, which actually is incapacitating
          since you cannot walk on it, and
          as a foot soldier in wwII not a good thing
          cauda equina