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Long-Acting Opioids for Refractory Chronic Migraine: Patient Selection and Guidelines for Use
Lawrence D. Robbins, M.D., Assistant Professor of Neurology,
Rush Medical College, Chicago
Posted: May 2009
To be presented at the October 2009 meeting of the American Academy of Pain Management
Background: Many patients with chronic migraine (CM) are refractive to the usual therapies. A number of studies have demonstrated limited rates of success with long-acting opioids (LAO’s).
Objective: To provide a practical guideline for opioid use in refractory CM patients.
Methods: This guideline was developed from the author’s studies on LAO’s and a review of the literature.
PATIENT SELECTION: Choose patients who: 1. fulfill criterion for refractory CM, 2. are reliable and known to the physician, 3. have demonstrated a good response to short-acting opioids without abusing them, 4. are older; younger patients develop tolerance more readily, 5. do not have a personality disorder, severe anxiety or depression.
MULTIDISCIPLINARY APPROACH: A biopsychosocial approach involves others such as psychotherapists, physical therapists, biofeedback practitioners. Active coping and improved patient functioning are vital.
PHASES OF TREATMENT: Initially, screening and risk assessment are done and the opioid agreement is signed. Assessed are: pain level, moods and functioning. If possible, consult with family members, primary care physician, and a psychologist. The second phase includes ongoing assessment of pain level, functioning, moods, abuse or AE’s. A brief PE assesses for slurring, abnormal gait, pupillary abnormalities. The third phase is switching or withdrawing from the opioid due to abuse or declining efficacy.
DOSING AND TITRATIONS: Higher doses rarely work out long-term. The usual range in our practice is methadone, 5-40 mg. daily; morphine (long-acting) 20-90 mg. daily; oxycodone CR, 20-60 mg. daily; fentanyl patch, 25-50 mcg.
OPIOID AGREEMENT: This sets limits, educates, discusses termination criteria, etc.
URINE TESTING: The two purposes are to identify other substances present and to detect levels of the opioid.
BREAKTHROUGH PAIN: Prescribing short-acting opioids increases abuse rates.
TOLERANCE: Younger patients are more likely to become tolerant. To change opioids, start at 40-70% of the equivalent dose.
ABUSE AND CHEMICAL COPING: Minor aberrant behaviors early in treatment are often overlooked. Pay attention to red flags, especially in new patients. Pervasiveness and severity of abusive behaviors must be considered. Opioids should not be used for moods, stress or anxiety.
Conclusion: n a small number of patients, long-acting opioids may significantly improve pain and quality of life. With careful patient selection and close monitoring, certain patients may do well long-term.
- Haas DC, Sheehe PR. Dextroamphetamine pilot crossover trials and n of 1 trials in patients with chronic tension-type and migraine headache. Headache. 2004; 44(10):1029-37.