Abstract
The use of opioid medications for treating chronic noncancer pain is growing; however,
there is a lack of good evidence regarding their long-term effectiveness, association
with substance abuse, and proper prescribing guidelines. The current study directly
compares for the first time in a randomized trial the effectiveness of a conservative,
hold the line (Stable Dose) prescribing strategy for opioid medications with a more
liberal dose escalation (Escalating Dose) approach. This 2-arm, parallel, randomized
pragmatic clinical trial followed 135 patients referred to a specialty pain clinic
at a Veterans Affairs Hospital for 12 months (94% male and 74% with musculoskeletal
pain). Primary outcomes included monthly or quarterly evaluations of pain severity,
pain relief from medications, pain-related functional disability, and opioid misuse
behaviors. All subjects received identical pain treatment except for the application
of treatment group specific strategies for opioid prescriptions. No group differences
were found for primary outcomes of usual pain or functional disability although the
Escalating Dose group did show a small but significantly larger increase in self-rated
pain relief from medications. About 27% of patients were discharged over the course
of the study due to opioid misuse/noncompliance, but there were no group differences
in rate of opioid misuse.
Perspective
The results of this study demonstrate that even in carefully selected patients there
is a significant risk of problematic opioid misuse. Although in general there were
no statistically significant differences in the primary outcomes between groups, the
escalating dose strategy did lead to small improvements in self-reported acute relief
from medications without an increase in opioid misuse, compared to the stable dose
strategy.
Key words
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Article info
Publication history
Published online: November 29, 2010
Accepted:
September 21,
2010
Received in revised form:
September 16,
2010
Received:
April 12,
2010
Footnotes
Grant support provided by Department of Veterans Affairs, Health Services Research and Development.
The authors report no conflicts of interest regarding this study.
Identification
Copyright
Published by Elsevier Inc.
