Recommended guidelines for opioid treatment
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In this final installment of our series on opioid medications we will be exploring the guidelines recommended by leading headache experts. In case you’re just now joining in, please take a look at A balancing act – opioid use throughout history, Risks of long-term opioid treatment, and Migraine-specific opioid treatment to catch up.


Dr. John Rothrock explains that there is bias against prescribing opioids among headache specialists. Part of the trouble has been that until recently patients with Chronic Migraine have been excluded from clinical studies. Doctors are generally averse to using treatments not supported by a lot of research. His recommendation is that the use of short-acting opioid as a rescue treatment for severe migraine “would appear both sensible and medically appropriate” when compared to the options of either allowing the patient to suffer or referring the patient to the ER3.

The American Headache Society cautions the regular use of short-acting opioids as a migraine treatment, call them “a double-edged sword”. They remind doctors and patients that no one is immune to the addictive potential of opioids and makes recommendations for their safer use1.

  1. Opioid prescriptions from only one physician
  2. Filled at only one pharmacy
  3. Prescriptions should specify precisely how long the quantity is supposed to last
  4. Early refill requests should be discouraged
  5. Dose should be administered as soon as the headache reaches moderate to severe pain intensity
  6. Use the lowest effective dose
  7. Patient education to include:
    1. Patient responsibility to take as prescribed
    2. side effects versus allergic reaction
    3. limit use to a maximum of twice weekly
    4. increased risks
      1. reduced effectiveness if waiting too long to take a dose
      2. worsening migraine with overuse
      3. becoming less responsive to other acute migraine medications

A study conducted by Dr. Lawrence Robbins evaluated headache patients diagnosed with refractory chronic migraine who had been prescribed long-acting opioids between 2002 and 2007 after failing multiple preventive and abortive medicines. All of these patients had done well on short-acting opioids in the past. Comorbid conditions were considered to determine if their presence affected the risk for abuse. They took into account numerous factors, including the presence of mental illness, exercise, coping skills, employment, disability status, and chronic fatigue2.

Results:

  • Average length of opioid treatment was 4.5 years
  • 73% reported side effects
  • The most common side effects were constipation, fatigue, and nausea
  • 69% of patients with Migraine for 3-15 years prior to opioid use responded positively to treatment
  • 61% of patients with Migraine for 16+ years prior to opioid use responded positively to treatment
  • The abuse rate was 26%
  • Patients with comorbid personality disorder and those with a history of abusing short-acting opioids were at increase risk of abuse.

For the purpose of this study, abuse included a wide variety of behaviors, including things like accepting another prescription from a dentist or taking the medicine for pain other than Migraine. Abuse is on a continuum from the occasional use of a family member’s Rx to habitual abusers. Not everyone who abuses opioids is an addict2.

The study recommends that treatment be divided into three phases:

  1. Initiation – risk assessment, patient education, medication agreement
  2. Monitoring – Ongoing assessment of patient’s pain, overall functioning, side effects, and medication compliance
  3. Transition – Switching to non-opioid pain management when abuse occurs or treatment fails to have the desired effect

Robbins states that only 50% of chronic migraineurs do well on long-term preventives. He recommends careful screening of these patients to determine if they are candidates for long-term opioid therapy. A select few will do well.  Ideal candidates are more likely to be young, with no prior opioid abuse, and good coping skills. Patients who smoke cigarettes and many with mental illnesses are not at increased risk for abuse and should not be excluded on those grounds. Those who previously abused opioids, older patients, and those diagnosed with personality disorders were at an increased risk for abuse2.

view references
  1. American Headache Society (2007). Opioid therapy for Migraine, Headache, doi: 10.1111/j.1526-4610.2007.00931.x, retrieved 2/15/2015 at http://www.americanheadachesociety.org/assets/1/7/Opioid_Therapy_October_2007.pdf.
  2. Robbins, Lawrence, MD, (March 2009). Long-Acting Opioids for Refractory Chronic Migraine, Practical Pain Management, Vol. 9, Issue 6, retrieved 2/15/2015 at http://www.practicalpainmanagement.com/pain/headache/migraine/long-acting-opioids-refractory-chronic-migraine.
  3. Rothrock, John F., MD, (July 2008). Treatment-refractory migraine: the case for opioid therapy, Headache, 48:850-854, retrieved 2/15/2015 at http://chicagoheadacheclinic.com/archives5/opioid_therapy.html.
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