Revista de la Sociedad Española del Dolor
versión impresa ISSN 1134-8046
ROBAINA PADRON, F. J.. Chronic lumbar and sciatic pain: Are we using opioids correctly? Spinal surgery vs morphine in the elderly. Rev. Soc. Esp. Dolor [online]. 2009, vol.16, n.1, pp.46-56. ISSN 1134-8046.
The specialist literature is sending out alarm signals spread by different organizations related to the study and treatment of noncancer pain and, specifically, the long-term pharmacological management of low back pain. The present article aims to draw attention to the problems resulting from the long-term use of potent opiates to control persistent pain due to degenerative lumbar disease, as well as to study the relationship between opiate medication and surgery in this type of disorder. To date, the units responsible for performing this type of surgery in the elderly generally seem not to accept, or to be reluctant to use, minimally-invasive techniques for spinal surgery, thus obliging many patients to undergo protracted treatment with potent opiates. Recent publications have alerted us to the risk of addiction resulting from prolonged opiate treatment, the frequency of addiction varying between 5 and 24%. Clearly, there is a risk to patients, society in general and physicians. Visits to the hospital emergency departments due to fentanyl abuse increased 50-fold between 1994 and 2002. Not all healthcare professionals keep their knowledge up-to-date and develop the skills required to provide effective treatment (guilty of ignorance). Opiates can activate neurophysiological pronociceptor mechanisms, creating a situation of increased pain sensitivity, which has been described as opiate-induced hypersensitivity (OIH). The long-term decrease in analgesic efficacy is most probably related to OIH; between 18% and 41% of patients may abuse these medications. Between 1999 and 2002, the number of deaths associated with opiate intoxication increased by 91.2% in the USA. There is a need for more in-depth studies on the relationship between cerebral structural changes and the neuro-physiological / neurochemical mechanisms of nociceptor transmission in relation to chronic opiate use. There is talk of "medicine flying blind" in the prescription of opiates for the long-term management of lumbar pain of musculo-skeletal origin. Recently, in the field of surgical instrumentation, as well as in the market of analgesic medication, there has been a certain distrust of the results of published studies. There are sufficient scientific reasons, both basic and clinical, to seriously question the long-term use of potent opiates for the control of noncancer low back pain. The guidelines and protocols developed by primary and specialist care professionals (management by processes) encourages better management and control of this type of pain. There is no need to continue with the current situation of opting out of spinal surgery in the old or very old merely because of age and of introducing the patient to an environment of morphine-on-demand. Purely economic reasons are inadmissible and the clinical reasons are unappealing.
Palabras clave : Chronic back pain; Opiates; Spinal surgery; Hyperalgesia; Addiction.