opioids

Chronic Pain Symptoms May Not Improve With Higher Opioid Doses

Increasing opioid doses does not appear to help improve symptoms in patients with chronic pain, and can lead to an increased risk of adverse effects, according to the results of 2 recent studies.

“Prescribers are often confronted with the decision to escalate opioid doses to achieve adequate analgesia. Understanding the impact of dose escalation on pain intensity is warranted,” the researchers wrote.1

They conducted a retrospective cohort study involving veterans with chronic pain, comparing 32,420 dose maintainers (±20% change in average morphine milligram equivalent [MME] daily dose) and 20,767 dose escalators (>20% increase in average MME daily dose). Participants were assessed over 2 consecutive 6-month windows of time.

They used the Numeric Rating Scale (NRS) to measure pain intensity. Overall, pain scores were higher among dose escalators at each 90-day time period following the index date but were not different in the 90 days prior to the index date.

“Opioid dose escalation among patients with chronic pain is not associated with improvements in NRS pain scores,” they wrote.

In a companion study by the same team, the researchers examined the potential adverse effects of dose escalation among the same groups of dose maintainers and dose escalators.2 A composite measure of subsequent substance use disorders (SUDs), including opioid, non-opioid, and alcohol use disorders, as well as opioid-related adverse outcomes (AOs) was measured, as well as individual SUDs and AOs.

Overall, composite AOs and individual SUD and AO subtypes (except for opioid-related accidents and overdoses and violence-related injuries) were higher in dose escalators than in dose maintainers. Sensitivity analyses adjusted and stabilized inverse probability of treatment weighting logistic regressions found similar outcomes, although in these analyses, opioid-related accidents and overdoses were found to be significantly higher among escalators.

“Escalating the opioid dose for those with chronic, non-cancer pain is associated with increased risks of substance use disorder and opioid-related adverse outcomes,” they concluded.

—Michael Potts

References:

  1. Hayes CJ, Krebs EE, Hudson T, et al. Impact of opioid dose escalation on pain intensity [published online January 7, 2020]. Pain. doi: 10.1097/j.pain.0000000000001784. Accessed February 6, 2020.
  2. Hayes CJ, Krebs EE, Hudson T, et al. Impact of opioid dose escalation on the development of substance use disorders, accidents, self‐inflicted injuries, opioid overdoses and alcohol and non‐opioid drug‐related overdoses: a retrospective cohort study [published online January 15, 2020]. Addiction. https://doi.org/10.1111/add.14940. Accessed February 6, 2020.