How do different opioids compare in terms of potency and effectiveness. What are the key considerations when choosing between long-acting and short-acting opioids for chronic pain. How can healthcare providers tailor opioid therapy to individual patient needs. What are the latest evidence-based recommendations for using opioids to treat various chronic pain conditions.

Understanding Opioid Potency and Morphine Equivalents

Opioids are a class of powerful pain-relieving medications that are commonly used to treat moderate to severe pain. However, not all opioids are created equal in terms of their potency and effectiveness. To standardize comparisons between different opioids, healthcare providers often use the concept of morphine milligram equivalents (MME).

MME is a way to convert the dosage of various opioids to an equivalent dose of morphine. This allows for easier comparison of the relative strengths of different opioid medications. For example, 1 mg of hydromorphone is equivalent to about 4 mg of morphine, while 1 mg of methadone can be equivalent to 3-10 mg of morphine, depending on the total daily dose.

Why are morphine equivalents important?

Understanding morphine equivalents is crucial for several reasons:

• It helps healthcare providers switch patients from one opioid to another safely
• It allows for more accurate assessment of a patient’s total opioid intake
• It aids in determining appropriate dosing when combining different opioids
• It helps in comparing the relative potency of different opioid medications

Healthcare providers should be aware that while MME conversions are useful, they are not exact and can vary based on individual patient factors. Careful monitoring and dose adjustments are always necessary when changing opioid medications or dosages.

Long-Acting vs. Short-Acting Opioids: Tailoring Treatment to Patient Needs

When it comes to managing chronic non-cancer pain, healthcare providers have a choice between long-acting (extended-release) and short-acting (immediate-release) opioid formulations. Each type has its own advantages and disadvantages, and the choice often depends on the individual patient’s needs and pain characteristics.

Characteristics of long-acting opioids:

• Provide steady pain relief over an extended period (usually 8-72 hours)
• May improve sleep quality by maintaining pain control overnight
• Can reduce the frequency of dosing, potentially improving adherence
• May help minimize the “peaks and valleys” of pain relief associated with short-acting opioids

Characteristics of short-acting opioids:

• Provide rapid onset of pain relief (usually within 15-30 minutes)
• Useful for managing breakthrough pain or pain that fluctuates throughout the day
• Allow for more flexible dosing based on activity levels or changing pain intensity
• May be preferred for patients with intermittent pain or those who require opioids only occasionally

When choosing between long-acting and short-acting opioids, healthcare providers should consider factors such as the patient’s pain pattern, daily activities, sleep quality, and risk of opioid misuse or addiction. In many cases, a combination of long-acting and short-acting opioids may be used to provide both baseline pain control and management of breakthrough pain.

Efficacy of Opioids in Chronic Non-Cancer Pain Management

The use of opioids for chronic non-cancer pain has been a topic of extensive research and debate in recent years. While opioids can be effective for many patients, their long-term use comes with significant risks and potential side effects.

A meta-analysis by Furlan et al. (2006) found that opioids were effective for treating chronic non-cancer pain, with improvements in pain and functional outcomes compared to placebo. However, the authors noted that the magnitude of benefit was often small to moderate, and side effects were common.

Which chronic pain conditions respond best to opioid therapy?

Research suggests that opioids may be more effective for certain types of chronic pain than others:

• Neuropathic pain: A systematic review by Eisenberg et al. (2005) found that opioids were effective for neuropathic pain, although the quality of evidence was limited.
• Osteoarthritis: Avouac et al. (2007) conducted a meta-analysis showing that opioids provided significant pain relief and improved function in patients with osteoarthritis.
• Low back pain: The American College of Physicians and American Pain Society guidelines (Chou et al., 2007) suggest that opioids may be an option for patients with severe, disabling chronic low back pain that has not responded to other treatments.

Despite these potential benefits, it’s important to note that the long-term efficacy of opioids for chronic pain remains uncertain. Ballantyne and Shin (2008) reviewed the evidence and concluded that while opioids can provide short-term pain relief, there is limited evidence supporting their long-term effectiveness.

Opioid Side Effects and Risk Management Strategies

While opioids can be effective for pain management, they are associated with a range of potential side effects and risks. Healthcare providers must carefully weigh these risks against the potential benefits when considering opioid therapy for chronic pain.

What are the most common side effects of opioid use?

Common opioid side effects include:

• Constipation
• Nausea and vomiting
• Drowsiness and sedation
• Cognitive impairment
• Respiratory depression (especially at higher doses)
• Hormonal changes (e.g., decreased testosterone levels)
• Increased risk of falls and fractures, particularly in older adults

To mitigate these risks, healthcare providers should implement strategies such as:

1. Starting with low doses and titrating slowly
2. Regular monitoring of pain levels, function, and side effects
3. Prescribing prophylactic treatments for common side effects (e.g., laxatives for constipation)
4. Educating patients on proper use, storage, and disposal of opioids
5. Implementing opioid risk assessment tools and urine drug screening when appropriate
6. Considering opioid rotation if side effects persist despite dose adjustments

Additionally, healthcare providers should be aware of the risk of opioid misuse, addiction, and overdose. The Centers for Disease Control and Prevention (CDC) has published guidelines for prescribing opioids for chronic pain, which emphasize the importance of assessing risks and benefits, establishing treatment goals, and regularly re-evaluating the need for continued opioid therapy.

Alternative and Adjunctive Therapies for Chronic Pain Management

While opioids can be effective for some patients with chronic pain, they are not always the most appropriate or safest option. Healthcare providers should consider a range of alternative and adjunctive therapies as part of a comprehensive pain management strategy.

Which non-opioid medications can be effective for chronic pain?

Several classes of medications have shown efficacy for various chronic pain conditions:

• Nonsteroidal anti-inflammatory drugs (NSAIDs): Effective for inflammatory pain conditions such as osteoarthritis
• Antidepressants: Particularly tricyclic antidepressants and serotonin-norepinephrine reuptake inhibitors (SNRIs) for neuropathic pain
• Anticonvulsants: Gabapentin and pregabalin are commonly used for neuropathic pain
• Topical agents: Lidocaine patches or capsaicin cream for localized neuropathic pain
• Muscle relaxants: May be helpful for chronic low back pain with muscle spasms

In addition to pharmacological approaches, non-pharmacological therapies can play a crucial role in managing chronic pain:

• Physical therapy and exercise programs
• Cognitive-behavioral therapy
• Mindfulness and relaxation techniques
• Acupuncture
• Transcutaneous electrical nerve stimulation (TENS)
• Interventional procedures (e.g., nerve blocks, radiofrequency ablation)

A multimodal approach that combines various treatment modalities is often the most effective strategy for managing chronic pain. This approach allows for lower doses of individual medications, potentially reducing side effects and improving overall outcomes.

Opioid Prescribing Guidelines and Best Practices

Given the potential risks associated with opioid use, several professional organizations have developed guidelines to promote safe and effective opioid prescribing for chronic pain. These guidelines provide evidence-based recommendations to help healthcare providers make informed decisions about opioid therapy.

What are the key recommendations from major opioid prescribing guidelines?

While specific recommendations may vary, common themes across guidelines include:

1. Exhausting non-opioid and non-pharmacological options before considering opioid therapy
2. Conducting a thorough patient assessment, including pain history, physical examination, and risk evaluation for opioid misuse
3. Setting realistic treatment goals focused on function and quality of life, not just pain intensity
4. Starting with low doses and titrating slowly, using immediate-release formulations initially
5. Regular monitoring of pain, function, and adverse effects
6. Implementing strategies to mitigate risks (e.g., using prescription drug monitoring programs, urine drug testing)
7. Providing patient education on safe use, storage, and disposal of opioids
8. Having a plan for tapering or discontinuing opioids if benefits do not outweigh risks

The CDC Guideline for Prescribing Opioids for Chronic Pain, released in 2016 and updated in 2022, provides comprehensive recommendations for primary care clinicians. Similarly, the American Pain Society and the American Academy of Pain Medicine have published consensus guidelines on the use of opioids for chronic non-cancer pain.

Healthcare providers should familiarize themselves with these guidelines and incorporate them into their clinical decision-making process. However, it’s important to remember that guidelines are not one-size-fits-all and should be applied in the context of individual patient needs and circumstances.

The Future of Chronic Pain Management: Emerging Therapies and Research Directions

As our understanding of chronic pain mechanisms evolves, researchers are exploring new approaches to pain management that may offer alternatives or complements to traditional opioid therapy. These emerging therapies hold promise for improving pain control while potentially reducing reliance on opioids.

What are some promising new directions in chronic pain research?

Several areas of research are showing potential for advancing chronic pain management:

• Targeted drug delivery systems: Developing novel formulations that can deliver pain medications directly to specific areas of the body, potentially reducing systemic side effects
• Abuse-deterrent opioid formulations: Creating new opioid formulations that are more difficult to misuse or abuse
• Non-opioid analgesics: Investigating new classes of pain medications that work through different mechanisms than opioids
• Neuromodulation techniques: Advancing technologies such as spinal cord stimulation and peripheral nerve stimulation for chronic pain
• Regenerative medicine: Exploring the use of stem cells and other regenerative therapies to treat chronic pain conditions
• Personalized medicine approaches: Developing genetic and biomarker-based methods to predict individual responses to pain treatments
• Virtual reality and other technological interventions: Utilizing immersive technologies to help manage pain and improve function

Additionally, there is growing interest in understanding the complex interplay between chronic pain, mental health, and social factors. This biopsychosocial approach to pain management emphasizes the importance of addressing psychological and social aspects of pain alongside biological factors.

As research in these areas progresses, it’s likely that we will see a shift towards more personalized, multimodal approaches to chronic pain management. These approaches may combine traditional pharmacological treatments with newer targeted therapies and non-pharmacological interventions, tailored to individual patient needs and risk profiles.

Healthcare providers should stay informed about these emerging therapies and consider participating in clinical trials or referring patients to specialized pain centers that offer access to cutting-edge treatments. By staying abreast of the latest developments in pain management, clinicians can provide their patients with the most up-to-date and effective care options.

A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain: Tailoring Therapy to Meet Patient Needs

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Alcohol and Drug Policy Commission : Opiates or Opioids — What’s the difference? : State of Oregon

Some people carefully distinguish between these two groups of narcotic drugs when they speak about them. Other people use the two terms interchangeably or prefer one over the other. Our language is evolving; lately many people, especially journalists and politicians (and this website), are tending to refer to all of these drugs as “opioids.”

Both opiates and opioids are used medically. They may be prescribed for pain relief, anesthesia, cough suppression, diarrhea suppression, and for treatment of opiate/opioid use disorder.

Both opiates and opioids may also be used illicitly by people with a substance use disorder.

The main difference is in how opiates and opioids are made.

Opiates

Opiates are chemical compounds that are extracted or refined from natural plant matter (poppy sap and fibers). Examples of opiates:

• Opium
• Morphine
• Codeine
• Heroin

Opioids

Opioids are chemical compounds that generally are not derived from natural plant matter. Most opioids are “made in the lab” or “synthesized.”

Though a few opioid molecules — hydrocodone (e.g., Vicodin), hydromorphone (e. g., Dilaudid), oxycodone (e.g., Oxycontin, Percocet) — may be partially synthesized from chemical components of opium, other popularly-used opioid molecules are designed and manufactured in laboratories. (The phrase “synthetic opioid” is considered redundant; nearly all opioids are synthesized.)

The pharmaceutical industry has created more than 500 different opioid molecules. Some are widely used medically, some are not. Examples of well-known opioids used medically in the U.S.:

• Dextromethorphan (available in the U.S. without prescription as, e.g., NyQuil, Robitussin, TheraFlu, Vicks)
• Dextropropoxyphene (e.g., Darvocet-N, Darvon)
• Loperamide (e.g., Imodium)
• Hydrocodone (e.g., Vicodin)
• Oxycodone (e.g., Oxycontin, Percocet)
• Oxymorphone (e.g., Opana)
• Meperidine (e.g., Demerol)
• Methadone (e.g., Dolophine)
• Fentanyl/fentanil (e.g., Ultiva, Sublimaze, Duragesic patch)
• Carfentanyl/carfentanil (e. g., Wildnil, for veterinary use)

Opiates and Opioids

Both groups of drugs are “narcotics.” (The word “narcotic” simply means sleep-inducing or numbness-inducing (from the Medieval Latin narcoticus, from the Greek narkoun “to benumb.”)  

It’s most precise to refer to both groups of narcotic drugs as “opiates and opioids,” the naturally derived and the synthetic. But currently, when people wish to refer to all of these drugs, they often use the term “opioid.”

If a person is dependent on (“addicted to”) one particular opiate or opioid drug, whether it’s medically prescribed or illicitly obtained, they may find that switching to a different opiate or opioid can help maintain their dependency or addiction. That is, substituting one opiate or opioid for another may help prevent withdrawal symptoms. Most of us have heard stories of people with real, actual, pain who became dependent on prescription pain-relieving narcotic drugs, then switched to illicit opioids or the opiate heroin when the medically supplied narcotics ran out.

Types of drugs that everyone should know about

Drug addiction is one of the most serious problems present in all corners of the world. In any country there are people who seek to get rid of difficulties and feel euphoria through the use of special substances and drugs. Types of drugs – this is a huge group of names, including heroin, cocaine, amphetamine, known to everyone, and names of drugs that do not have such popularity, but cause terrible consequences for the health and life of an addict.

What types of drugs are there? It will take a lot of time to list all the known names. But among them, one can single out the most popular and common ones that everyone needs to know about in order to be able to recognize the symptoms of addiction and provide timely assistance to the patient.

What is a drug?

To understand what types of drugs there are, you need to know what is meant by the general name of the drugs. A drug is a substance that, when ingested, replaces one or more of the substances involved in metabolism and causes addiction (dependence). In the absence of a new dose of the drug, withdrawal occurs, which can manifest itself with different symptoms.

It is impossible to combine all types of drugs with the same characteristics. Substances can be presented in different forms – tablets, powder, liquid, dry substance, etc. They have different external characteristics, are accepted differently and have different effects on the body.

All types of narcotic substances can be divided into several groups according to the principle of action:

• stimulants;
• depressants;
• Psychedelics or hallucinogens.

Stimulant substances have a stimulating effect on the nervous system. A person’s blood pressure rises, the heart rate quickens, and a surge of energy is felt.

Depressants, on the contrary, slow down the work of the nervous system. This group includes opiates obtained from poppy pods, as well as synthetically created analogues.

Hallucinogens contribute to a change in consciousness, sensations, perceptions. The drugs are also presented as natural (mushrooms, dope) and synthetic versions (LSD).

The most famous types of drugs: a list and description

Heroin and cocaine are among the most famous drugs that everyone should definitely know about.

Heroin is the most terrible narcotic substance, which originates from poppy fields in Afghanistan. This drug is opioid and synthetic in equal parts, originally created with a good purpose – for treatment. But the side effect of the drug turned out to be stronger than its benefits, and today it is exclusively a drug. The effect of taking heroin is manifested in the development of a state of apathy, detachment from the real world, which manifests itself as a kind of “high”. It is impossible to quit heroin on your own.

Cocaine is another drug that is being talked about. For the production of the substance, the Colombian bush Coca is used, from the leaves of which the drug is obtained. It has the opposite effect of heroin – it improves concentration, improves attention, and causes a feeling of confidence. Cocaine is instantly highly addictive. As a result of its impact on the body, a strong heartbeat, tachycardia occurs, pressure rises, which often causes heart attacks.

Types of “clubbing” drugs: barbiturates, ketamine and ecstasy

Many drugs can be bought in nightclubs and other “hangouts” of the younger generation. Most often we are talking about barbiturates – synthetic drugs created on the basis of sedative drugs used for treatment, but used strictly in doses determined by the doctor. As part of the drug, these doses are significantly exceeded, which leads to the appearance of a bright hallucinogenic effect and addiction. Often the outcome of dependence on barbiturates is death.

There are equally popular types of narcotic pills – ecstasy. The use of this synthetic stimulant leads to an increase in the level of adrenaline in the body, an increase in body temperature, a person feels overwhelmed with energy, does not feel tired. Ecstasy can also cause a heart attack.

Ketamine is another popular club drug. It is an anesthetic that causes very vivid and strong hallucinations when overdosed. Mental illness is a consequence of taking ketamine.

Other types of drugs

One of the analogues of heroin is methadone. It is symbolic that in the United States it is methadone that is used to treat heroin addiction. With uncontrolled intake, the drug is highly addictive. Withdrawals while taking methadone can last up to 2 weeks. An expensive analogue of “street” methadone is buprenorphine.

For medical purposes, drugs from the benzodiazepine group help to cope with depression, anxiety, insomnia. When using tranquilizers as a drug, there is a feeling of euphoria, relaxation, lightness. Dependence on benzodiazepines leads to mental and nervous system disorders.

Amphetamines (speed, hair dryer) – drugs that increase heart rate, increase activity, energy. A person ceases to feel tired, ready for new achievements and work without interruption. When taking a hair dryer, attention increases, concentration improves. After the end of the action of the drug, a period of apathy, fatigue, paranoia may appear.

Cannabis or weed is a popular “street” solution to the problems of sadness and despondency. Get the drug from the leaves, seeds, resin of hemp. You can use the substance both in food and as a smoking mixture. We will not list all the names of hemp drugs – we will limit ourselves to the most common ones. From pollen, plants produce marijuana, from resin – hashish, from leaves – marijuana.

LSD is a synthetic psychotropic substance that has a destructive effect on the perception of reality. Taking LSD is accompanied by hallucinations, loss of time, mental disorders. LSD does not cause addiction and withdrawal, but even a single use of the drug leads to very serious consequences for the body.

Solvents, glues, paints used by those who like to inhale toxic substances are also addictive and addictive. Taking drugs causes a feeling of euphoria and loss of control over one’s own actions, which often leads to suicide or an accident.

Legal drugs

In some countries drugs are legalized and can be used quite legally. Among these drugs – cat. It is a natural stimulant made from the leaves of a South American plant. It is used in the form of chewing gum.

In Ukraine, all narcotic substances permitted for use in other countries are prohibited. But this prohibition does not negate the fact that many medications used to treat depression, insomnia, and anxiety disorders turn into hard drugs when the dosage is incorrect. It turns out that it will not be possible to eliminate absolutely all types of known drugs from sale, because it is impossible to deprive patients of effective drugs, and it is almost impossible to block drug addicts from accessing the same drugs.

Types of drugs, their properties and effects on the body

Cannabis preparations

The main narcotic substance in the preparations of this group is cannabinol , and in total more than 60 cannabinoids, substances that have a narcotic effect, were found in hemp.

Cannabis preparations change consciousness, cause fantasies and hallucinations. The euphoria that occurs at the first stages of taking the drug is quickly replaced by the stage of oppression. Thinking slows down, mood changes dramatically, crazy ideas appear, caused by an altered consciousness. Long-term use of cannabis-based drugs can lead to psychosis, in which an addicted person is capable of the most unpredictable actions.

The main drugs of the group are marijuana and hashish.

Opiates

Opiates are narcotic drugs that cause a sedative, “inhibitory” effect. Taking opium, a person experiences euphoria and peace. Drugs of the opium subgroup provoke rapid addiction and severe mental and physical drug addiction, which is difficult to cure.

Opiates have a devastating effect on the organs and systems of the body. Over time, the addict develops severe mental disorders – deep depression, mood swings, bouts of despair, suicide attempts.

The opium group includes all synthetic and natural derivatives of opium obtained from the poppy:

with the strongest narcotic effect. Heroin quickly causes physical addiction. The high toxicity of the drug provokes destructive consequences for the whole organism.

Amphetamines

Amphetamines have a psychostimulant effect. Drugs are made from pharmaceutical preparations containing ephedrine. Usually drugs of this group are administered intravenously. Perhaps smoking or inhaling crystals obtained from the ephedra plant.

Drugs form a “drunken” addiction, when periods of use alternate with breaks. With regular use, breaks are reduced, and a strong physical and mental drug addiction is formed, accompanied by a constant increase in the dose. Amphetamines provoke aggressiveness, excessive anxiety and anger.

Amphetamine drugs:

• ephedron;
• pervitin;
• ephedrine.

Cocaine

Cocaine is a narcotic substance found in the leaf of the tropical coca plant. The allocation of cocaine to a separate group of drugs is due to its extensive distribution. According to its pharmacological effects, the drug belongs to stimulants that simultaneously cause euphoric effects. Moreover, each subsequent dose of cocaine increases the effect of euphoria.

Cocaine is a white crystalline powder, usually consumed by inhalation. Cocaine hydrochloride dissolved in water can be administered intravenously or taken orally.

The use of cocaine is accompanied by excitement, which is then replaced by depression of the nervous system. Drug addiction develops imperceptibly, but steadily. An increase in repeated narcotic doses accelerates addiction to cocaine and can lead to nervous exhaustion in the addicted patient.

Hallucinogens

This group includes drugs that alter consciousness and cause a hallucinogenic effect.

The most common drugs are:

• LSD;
• psilocin;
• psilocybin.

Ecstasy

This group includes synthetic amphetamine-type stimulants, often with hallucinogenic effects.