Opioid Tolerance

When engaging in long-term opioid management for chronic pain, should healthcare providers discuss with their patients the fact that the medications won’t typically remain effective for the rest of their life? That is to say, should healthcare providers fully review the implications of opioid tolerance prior to beginning long-term opioid management for patients who have chronic pain, but who are neither elderly nor sick with a terminal illness?

If you have chronic pain and are on long-term use of opioids, and are middle-aged or younger, did your healthcare provider discuss the implications of opioid tolerance with you? The Institute for Chronic Pain website has a new content page that tackles this important yet complex issue.

While the issue of addiction tends to dominate debates over opioid management for chronic pain, the field remains largely silent about another important issue with regard to the long-term use of opioids. It is the issue of opioid tolerance. Tolerance is a phenomenon that occurs when an individual over time requires greater amounts of a drug to continue to obtain the original degree of its desired, therapeutic effect (Savage, et al., 2003). Tolerance to a medication becomes problematic when, on the one hand, patients taking the medication have many years yet to live and, on the other hand, it is not feasible to expect that they can continue to periodically increase the dose of the medication indefinitely. As such, this problem is particularly applicable to chronic pain patients on long-term opioid management who have a reasonably long life expectancy – another twenty or thirty or forty more years to live.

It leads to the inevitable question: What will chronic pain patients do when, after years of periodically increasing the dose whenever their opioid medication started to become less effective, they find themselves on the highest dose of an opioid and even this level of the medication no longer effectively reduces their pain? In other words, what happens when patients become opioid tolerant to the highest doses of the medication and still have many years yet to live? The field of chronic pain management has now had patients on the long-term use of opioids for almost two decades and as a result it is increasingly common to see opioid tolerant patients in clinic – patients who have been on these medications for many years and are finding that the medications are no longer very effective even when they are on the conventionally agreed upon highest doses.

This increasingly common clinical problem is chockfull of ethical implications:

• What now is our shared responsibility for the care of such patients?
• Should the field have done better at predicting this problem, given what historically we knew about tolerance to drugs and medications?
• Are we as a field routinely providing informed consent by discussing with our patients the long-term consequences of opioid tolerance with our current patients?
• How much are we helping patients if we allow them to become opioid tolerant to the highest doses of the medications when they have many years yet to live?
• How are we going to treat such patients in the future if they have an altogether different painful injury or illness? How will we manage the opioid tolerant patient’s pain if, for instance, the patient later in life develops a terminal cancer or falls and breaks a hip and requires surgery when elderly?
• Should we continue the practice of long-term opioid management for patients who are neither elderly nor terminally ill (i.e., people with chronic pain for whom we might reasonably expect to live more than a decade or two)?
• Should we continue to engage in long-term opioid management for such patients when we know we have an empirically supported, effective alternative to opioids for people with chronic pain – the interdisciplinary chronic pain rehabilitation program?

Despite our persistent failure to discuss it, the topic of opioid tolerance demands of us to openly acknowledge it. It is an increasingly common clinical problem for chronic pain patients and their providers alike. Moreover, it leads to a slew of ethical problems that require resolution.

For a more in depth discussion of these issues, please read Tolerance to Opioid Pain Medications on the Institute for Chronic Pain website.

References

Savage, S. R., Joranson, D. E., Covington, E. C., Schnoll, S. H., Heit, H. A., & Gilson, A. M. (2003). Definitions related to the medical use of opioids: Evolution towards universal agreement. Journal of Pain and Symptom Management, 26(1), 655-667.

Author: Murray J. McAllister, PsyD

Date of last modification: 7-18-2014