Opioid Use in Treating Chronic Headache

Dr. Joel R. Saper reviews the use of opioid medication for headache and the results of an MHNI study on the often controversial topic.

What is the difference between short-acting and long-acting opioid medications?

The difference between short-acting and long-acting opioid medication involves the duration of analgesic effect. Generally speaking, short-acting opioids work for 3-4 hours, peaking at approximately 2-3 hours after administration. Long-acting opioids are designed to work from 24 hours to 8-12 hours per dose. Many patients using long-acting opioids, however, require more frequent dosing for ideal pain control. The Duragesic patch (the narcotic fentanyl is released from the patch to the skin) has a duration of action for up to 72 hours per patch application.

What are common side effects for opioid medications?

All opioid medications cause physical dependency. This means that with frequent usage, the body becomes physiologically dependent on the medication and sudden discontinuance will produce withdrawal symptoms. Some patients also become emotionally or psychologically dependent on these medications, usually from their effect on mood, which includes a "buzz" feeling and tranquilization. "Addictive disease" is defined as physiological and/or psychological dependency, in conjunction with inappropriate drug-seeking behavior, including usage for reasons other than pain, multisourcing, forgery, etc. Relatively few patients with legitimate pain fulfill the criteria for "addictive disease" as defined in this way.

Tell us more about the use of long-acting opioid medications for chronic pain including migraine headache

MHNI professionals are recommending in their various teaching forums and publications that certain guidelines may help to define treatment-eligible patients for opioid therapy. Except rarely, patients should not be placed on chronic opioid treatment unless they have demonstrated clear and convincing failure to respond to a variety of other less potentially troubling therapies. We do not think this treatment is appropriate for young patients with chronic headache, patients with personality disorders, or those with a history of chronic misuse of medication.

Of concern is the potential long-term effects of chronic opioid treatment, particularly in middle-aged or young patients. There is some concern that long-term usage could in fact alter forever the physiological mechanisms of pain modulation in the central nervous system, and thus render a patient more vulnerable to pain whenever the medication is reduced. Other long-term risks have simply not been studied.

Study Results

MHNI recently completed a 5-year follow-up study on the use of long-acting opioid medications for the treatment of intractable headache. What were the results of this study?

The results of MHNI's 5-year study show that less than 25% of chronic headache patients, when given opioids daily, actually benefited in a clear and measurable way. Over half of the patients requested or required discontinuation of the medications soon after they were administered. Another 25% continued to take the medication with only marginal benefit. Twenty-three percent (23%) showed substantial benefit. Relatively few patients who reported feeling better reduced the use of other medications for headache.

Unfortunately, many patients who successfully took the narcotic medications demonstrated misuse patterns, which included altering dosages without physician approval, losing certain medications, etc.

One positive finding was a reduction in hospitalization and emergency department usage in the group that improved. The results of this study thus suggest that a small but important percentage of patients who have failed the most advanced care for the treatment of their head pain will benefit from chronic opioids. Such patients must be selected carefully and must be responsible and compliant with treatment limitations.