From the Guidelines
Opioids should be avoided in Parkinson's disease management due to their potential to worsen motor symptoms and create additional complications, and instead, non-opioid analgesics like acetaminophen or NSAIDs should be tried first. When pain management is necessary in PD patients, the treatment approach should prioritize minimizing harm and optimizing quality of life. According to the most recent guideline evidence 1, the use of opioids in pain syndromes more commonly leads to loss of efficacy than is seen in RLS alone, and RLS is prevalent in people with Parkinson's disease.
The potential risks associated with opioid use in PD patients include worsening constipation, confusion, sedation, and respiratory depression, as well as potential interference with dopaminergic transmission, exacerbating PD motor symptoms 1. Additionally, opioids may interact with monoamine oxidase B inhibitors like selegiline or rasagiline, potentially causing serotonin syndrome.
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 5mg every 6 hours) being relatively safer options 1. However, the use of any opioids for management of chronic neuropathic pain carries the risk of addiction and should be avoided.
Key considerations for opioid use in PD patients include:
- Using the lowest effective dose for the shortest duration possible
- Monitoring for worsening of PD symptoms, cognitive changes, and respiratory status
- Implementing a bowel regimen to mitigate constipation
- Carefully evaluating the risks and benefits of opioid therapy, including the potential for addiction and interaction with other medications.
Overall, the management of pain in PD patients requires a careful and individualized approach, prioritizing non-opioid analgesics and minimizing the use of opioids to optimize quality of life and minimize harm.
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.
- Other treatments for chronic pain in PD include dopaminergic agents, acetaminophen, NSAIDs, antidepressants, physical therapies, and deep brain stimulation, which can be used in combination with opioids to manage pain effectively 2, 6.
Treatment Options
- Dopaminergic agents, such as levodopa-carbidopa, pramipexole, and apomorphine, can help manage PD-associated pain 2.
- Non-opioid analgesics, such as acetaminophen and NSAIDs, can be used to treat mild to moderate pain in PD patients 2.
- Anticonvulsants, such as gabapentin and pregabalin, and antidepressants, such as selective serotonin and noradrenaline reuptake inhibitors, can also be used to manage chronic pain in PD 2.
- Deep brain stimulation of the subthalamic nucleus has been shown to be effective in managing PD-associated pain symptoms 2.
Safety and Efficacy
- The safety and efficacy of opioids in PD patients should be carefully evaluated, as long-term use can lead to neurobehavioral consequences and exacerbate PD symptoms 4.
- A thorough assessment of patient history and physical examination should be made to manage chronic pain effectively in PD patients 2.
- The use of opioids in combination with other treatments, such as dopaminergic agents and non-opioid analgesics, may be necessary to manage chronic pain in PD patients effectively 2, 6.