Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD

Abstract

Study design

Online questionnaire of spinal cord injury (SCI) physicians.

Objectives

The objective of this study is to characterize the approach to opioid prescription for persons with spinal cord damage (SCD).

Setting

An international online questionnaire.

Methods

A survey was posted online and circulated among international societies within the field of SCI medicine from August to November 2018.

Results

One hundred and twenty-three physicians responded to the survey. Of these, 107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line.

Conclusion

Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid-use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.

from$8.99

All prices are NET prices.

Fig. 1
Fig. 2
Fig. 3

References

  1. 1.

    Cardenas DD, Bryce TN, Shem K, Richards JS, Elhefni H. Gender and minority differences in the pain experience of people with spinal cord injury. Arch Phys Med Rehabil. 2004;85:1774–81.

  2. 2.

    Finnerup NB, Jensen MP, Norrbrink C, Trok K, Johannesen IL, Jensen TS, et al. A prospective study of pain and psychological functioning following traumatic spinal cord injury. Spinal Cord. 2016;54:816–21.

  3. 3.

    Siddall PJ, McClelland JM, Rutkowski SB, Cousins MJ. A longitudinal study of the prevalence and characteristics of pain in the first 5 years following spinal cord injury. Pain. 2003;103:249–57.

  4. 4.

    Finnerup NB, Attal N, Haroutounian S, McNicol E, Baron R, Dworkin RH, et al. Pharmacotherapy for neuropathic pain in adults: a systematic review and meta-analysis. Lancet Neurol. 2015;14:162–73.

  5. 5.

    Guy SD, Mehta S, Casalino A, Côté I, Kras-Dupuis A, Moulin DE, et al. The CanPain SCI Clinical Practice Guidelines for Rehabilitation Management of Neuropathic Pain after Spinal Cord: recommendations for treatment. Spinal Cord. 2016;54(Suppl 1):S14–23.

  6. 6.

    Bryce TN Unpublished data from SCI Model Systems 2019.

  7. 7.

    Rudd RA, Aleshire N, Zibbell JE, Gladden RM. Increases in drug and opioid overdose deaths–United States, 2000-2014. MMWR Morb Mortal Wkly Rep. 2016;64:1378–82.

  8. 8.

    Heron M. Deaths: leading causes for 2016 [Internet] (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2018) [cited 26 December 2018]. Available from: https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_06.pdf#page=1&zoom=auto,-41,798.

  9. 9.

    Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep. 2017;2:e599.

  10. 10.

    Husain SA. Opioid consumption data [Internet] 2015 [cited 23 January 2018]. Available from: http://ppsg-chartmedicine.wisc.edu.

  11. 11.

    Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain−United States, 2016. JAMA. 2016;315:1624–45.

  12. 12.

    Busse JW, Craigie S, Juurlink DN, Buckley DN, Wang L, Couban RJ, et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189:E659–66.

  13. 13.

    Häuser W, Bock F, Engeser P, Tölle T, Willweber-Strumpfe A, Petzke F. Long-term opioid use in non-cancer pain. Dtsch Arztebl Int. 2014;111:732–40.

  14. 14.

    Faculty of Pain Medicine and Public Health England. Opioids Aware: A resource for patients and healthcare professionals to support prescribing of opioid medicines for pain [Internet] (London: Royal-College-of-Anaesthetists, 2017) [cited 1 March 2019]. Available from: https://www.rcoa.ac.uk/faculty-of-pain-medicine/opioids-aware.

  15. 15.

    The Royal Australian College of General Practitioners. Prescribing drugs of dependence in general practice, Part C1: Opioids [Internet] (East Melbourne: RACGP, 2017) [cited 1 March 2019]. Available from: https://www.racgp.org.au/FSDEDEV/media/documents/Clinical%20Resources/Guidelines/Drugs%20of%20dependence/Prescribing-drugs-of-dependence-in-general-practice-Part-C2.PDF.

  16. 16.

    Raff M, Crosier J, Eppel S, Meyer H, Sarembock B, Webb D. South African guideline for the use of chronic opioid therapy for chronic non-cancer pain. S Afr Med J. 2013;104(1Suppl 1):78–89.

  17. 17.

    Hand BN, Krause JS, Simpson KN. Dose and duration of opioid use in propensity score-matched, privately insured opioid users with and without spinal cord injury. Arch Phys Med Rehabil. 2018;99:855–61.

  18. 18.

    Bryce TN. Opioids should not be prescribed for chronic pain after spinal cord injury. Spinal Cord Ser Cases. 2018;4:66.

  19. 19.

    Widerstrom-Noga E, Biering-Sorensen F, Bryce TN, Cardenas DD, Finnerup NB, Jensen MP, et al. The International Spinal Cord Injury Pain Basic Data Set (version 2.0). Spinal Cord. 2014;52:282–6.

  20. 20.

    Bryce TN. Pain Management in Persons With Spinal Cord Injury. In: Kirshblum SC, Lin VW (Eds.). Spinal Cord Medicine [Internet]. New York: Springer Publishing Company; p. 411–37. Available from: https://connect.springerpub.com/content/book/978-0-8261-3775-3/part/part04/chapter/ch25.

Download references

Author information

Correspondence to Thomas N. Bryce.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note: Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark