Providing straightforward information pertaining to drugs, drug use & drug policy. The Grey Pages promotes drug-related literacy and advocates a system of viable and tolerant drug policies. This is my personal collection of commentaries, essays, tid-bits, and other such writings on everything ranging from drug use, drug policy and drug-myths, to drug-science, addiction, human behavior, and the workings of the human brain. I started this blog with a particular focus on opioids, and over the past year have found my interest gravitate toward the intriguing, ever-changing world of designer intoxicants (i.e. "research chemicals" or "designer drugs").

Tuesday, January 11, 2011

Opioid Agonists and Their Place in Treatment - My Own Beliefs

The Views Discussed herein are product of my own personal opinion and experience, and should be interpreted as such. I base my claims on personal experience and clinical or scientific knowledge, rather than the arbitrary dictates of religious morality or sociopolitical bias.

Opioid Agonist Therapy Should Be Considered For:

For moderate to severe chronic pain that has been resistant to acetaminophen and NSAID's. 
For severe major depressive & anxiolytic disorders which have not responded to conventional treatments & pharmacotherapy; many of these subects may have a history of 'self medicating' using opioids, or may report that opioids have relieved symptoms in the past. 

Single entity-long acting opioids should typically be used in the treatment of psychic distress, in order to achieve steady plasma level & lead to a more stable emotional state. Gradually acting opioids additionally tend to have lower propensity for patterns of problematic use.

This option is to be discussed in depth with patients, and all risks/benefits must be disclosed, including the factor of clinical tolerance, clinical dependence and possible development of narcotic addiction. Discuss withdrawal syndrome upon discontinuation, and the difference between clinical dependence and addiction.

Opioid therapy should be seen as a supportive & palliative measure rather than a curative treatment; and when possible should be prescribed alongside primary forms of treatment such as Osteopathic Manipulative Therapy, acupuncture, physical & behavioral therapy, excersice & healthy diet, and other lifestyle changes. Peripheral nerve blocks & surgery may be an option in some cases; taking into consideration the risk-benefit ratio as well as the original objectives of treatment and financial concerns. The patient's desires concerning direction of treatment and goals/objectives will always be put first and foremost; physicians shall provide patients insight, guidance and support possible regarding their medical conditions, medications, and treatments, while disclosing all potential risks and side effects (especially concerning the addictive qualities of narcotic analgesics).

Hydrocodone and Acetaminophen & Oxycodone and Acetaminophen: These are common first line narcotics; they can be initiated at 1q6-8h doses, taken as needed - however patient preference or clinical requirement may eliminate the option of acetaminophen due to hepatic toxicity concerns. Likewise, oral NSAIDs are contraindicated in patients with a history of GI issues & peptic ulcers. In these cases, avoid combination analgesics (Vicodin, Percocet, Lortab).

Opioids should be started on an 'opioid trial' basis. Choice of analgesic should be based upon the patient's severity of symptoms, intensity of symptoms, frequency & duration of symptoms, overall health of the patient, physiological & metabolic factors, and patient preference. 

Patients should be regularly assessed for overall response & possible toxicity. Dose should be titrated (raised or lowered) according to response during the trial period. The need for opioids should additionally be reassessed periodically.

After a succesful trial of short acting opioids, being 4 weeks or more, a long acting formula can be prescribed for 24 hour baseline analgesia. An additional short acting opioid may be given alongside for supplemental analgesia or sudden onset pain. Preferred long acting opioids include OxyContin & MS Contin, Avinza & Kadian, Opana ER, Duragesic, Exalgo, as well as Methadone.

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