Maladaptive LTOT dependence and Opioid Induced Chronic Pain
Syndrome (OICP):
Despite the best intentions and efforts by patients and providers,
adaptive LTOT dependence that provides functional improvement and pain
control can and often does evolve over time into maladaptive LTOT
dependence or CPOD accompanied by the clinical phenomenology of OICP
irrespective of whether LTOT is continued or
discontinued.45 OICP often mimics the worsening of
musculoskeletal and other diseases associated with chronic pain and
seemingly unrelated medical and psychiatric diseases, thus potentially
causing providers and patients to fail to recognize the clinical impact
of OICP. Attributing worsening OICP to musculoskeletal deterioration can
encourage reliance on inappropriate tests and clinical evaluations that
can lead to ineffective and harmful treatments, including polypharmacy
and initiation or dose escalation of other potentially addictive
substances.52,53,65 These ineffective methods of
treating OICP may worsen overall health and function. Polysubstance use
and polypharmacy, especially with addictive medications like gabapentin,
benzodiazepines, and stimulants, can substantially increase clinical
complexity and patient distress. OICP has become more prominent with the
recent embracing of opioid tapering as a treatment of ineffective and
unsafe LTOT. In our clinical experience, treatment of the medical and
psychiatric conditions associated with OCIP may be futile and
reinstatement of opioid dose, albeit as a treatment of opioid
dependence, is often necessary.52,66
The insidious development of maladaptive LTOT dependence with OICP can
evade usual pain focused clinical evaluations because of confounding
clinical presentations. This raises the need for close follow up of
patients on LTOT to assess for development of OICP using specific
criteria. Thus, the increased recognition that patients on LTOT can
develop a paradoxical persistent pain syndrome raises the need for a set
of criteria for the identification of OICP.70 We
propose the following criteria enumerated in Box 2 as a starting point.
These criteria for identifying OICP should be revised with further
research and accumulation of clinical expertise and OICP can be perhaps
developed into a formal diagnostic terminology.
It is important not to confuse or equate OICP, a common clinical
phenomenon observed in clinical practice presumably driven largely by
non-nociceptive mechanisms, with opioid induced hyperalgesia (OIH), a
rare clinical phenomenology driven by nociceptive mechanisms. Allostatic
opponent effect is the shared theoretical explanation for both OICP and
OIH. 45,71 However, OIH is the clinical expression of
allostatic opponent effect confined to the nociceptive components of
pain experience that is associated with increased pain related to
hyperalgesia (a higher sensitivity to nociceptive stimuli).45,71 Prior authors have used the term hyperkatefia to
described the pain experience associated with allostatic opponent effect
on the non-nociceptive components of pain.69 OICP is
conceptualized as the increased global experience of pain, other
associated symptoms like depression, anxiety, fatigue and debility
mediated by non-nociceptive mechanisms and is not typically associated
with hyperalgesia in clinical practice.45
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