From the Guidelines
Opioids should be avoided in Parkinson's disease management due to their potential to worsen motor symptoms and cognitive function, and instead, non-opioid analgesics and optimizing dopaminergic therapy should be prioritized. When pain management is necessary in PD patients, non-opioid analgesics like acetaminophen (up to 3000mg daily in divided doses) should be tried first, followed by NSAIDs if appropriate 1. If opioids must be used for severe pain, they should be prescribed at the lowest effective dose for the shortest duration possible, with tramadol (starting at 25mg twice daily) or oxycodone (starting at 2.5-5mg every 6 hours) being relatively safer options, although their use carries the risk of addiction and should be avoided whenever possible 1.
Some key points to consider when managing pain in PD patients include:
- Avoiding meperidine completely as it can cause severe reactions with MAO-B inhibitors commonly used in PD
- Using stool softeners and laxatives concurrently with opioids to mitigate constipation, which is already problematic in PD
- Monitoring for side effects and drug interactions, particularly with dopaminergic medications
- Optimizing dopaminergic therapy as a first-line approach for PD-specific pain, as it often provides better relief than adding opioids
- Considering alternative pain management options, such as gabapentinoids, which have been shown to be effective in treating pain in other conditions, such as diabetic neuropathy 1.
Overall, the goal of pain management in PD patients should be to prioritize non-opioid analgesics and optimizing dopaminergic therapy, while minimizing the use of opioids and carefully monitoring for potential side effects and interactions.
From the Research
Opioids in Parkinson's Disease
- Opioids are commonly used to treat chronic pain in Parkinson's disease (PD) patients, with medications such as oxycodone, morphine, tramadol, and codeine being employed 2.
- A study on the efficacy and safety profile of prolonged release oxycodone in combination with naloxone (OXN PR) in PD patients with chronic pain found that low-dose OXN PR was efficacious for pain management without significant side effects 3.
- However, long-term utilization of tramadol, a synthetic analog of codeine, has been associated with neurobehavioral consequences, including seizures, serotonin syndrome, and neurotoxicity, which may exacerbate PD symptoms 4.
- A double-blind, randomized, placebo-controlled trial on prolonged-release oxycodone-naloxone for treatment of severe pain in PD patients found that while the primary endpoint was not significant, the results highlighted the potential efficacy of OXN PR for PD-related pain 5.
Treatment Options for Parkinson's Disease-Related Pain
- Dopaminergic agents, such as levodopa-carbidopa, pramipexole, and apomorphine, have shown efficacy in treating PD-associated pain 2.
- Non-dopaminergic treatments, including acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and cyclooxygenase-2 (COX-2) inhibitors, can also be effective in managing PD-related pain 2.
- Anticonvulsants, such as gabapentin and pregabalin, and tricyclic antidepressants (TCAs) may be trialed for chronic pain management in PD patients 2.
- Deep brain stimulation (DBS) of the subthalamic nucleus (STN) has been shown to be effective against various types of PD-associated pain symptoms 2.