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Chronic opioid dosing and driving IASP Symposium, Stanford, California 13.08.2002 Eija Kalso

Chronic opioid dosing and driving IASP Symposium, Stanford, California 13.08.2002 Eija Kalso. Issues to be discussed. Cognitive effects of pain Cognitive effects of opioids Traffic safety Tests in the laboratory Real life testing. Tests predicting the behind-the-wheel performance.

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Chronic opioid dosing and driving IASP Symposium, Stanford, California 13.08.2002 Eija Kalso

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  1. Chronic opioid dosing and drivingIASP Symposium, Stanford, California13.08.2002Eija Kalso

  2. Issues to be discussed • Cognitive effects of pain • Cognitive effects of opioids • Traffic safety • Tests in the laboratory • Real life testing

  3. Tests predicting the behind-the-wheel performance • visual scanning • attention • information-processing speed • visuospatial perception • visuopraxis • visual memory • planning-problem solving

  4. Behaviours that correlate with driving performance • distractability • difficulty in following directions • impulsivity • inattention • mental slowness

  5. Opioids and the CNS • sedation • mood • risk taking behaviour • cognitive functions • memory • vision

  6. Opioid use and fatal traffic accidents • Ray & al. 1992 (Tennessee): relative risk no higher than 1: opioids/antihistamines (higher than 1: benzodiazepines/antidepressants) • Budd & al. 1989 (Los Angeles): biological fluids: alcohol, marijuana, cocaine (opioids in 1/594) • Stoduto & al. 1993 (Ontario): 41.3% tested positive for alcohol/drugs: marijuana (14%), benzodiazepines (12%), opioids (<5%) • Gjerde &al. 1993 (Norway): alcohol (28%), drugs (cannabinoids/benzodiazepines) (16%), morphine/codeine (1.3%)

  7. Cancer patients: Pain vs Opioids: laboratorySjøgren & al Pain 2000;86:237

  8. Oral opioids, pain and performance • 130 consecutive cancer patients(40-76 yrs) • Gr 1 (n=40), KPS A; no pain, no oral opioids • Gr 2 (n=19) KPS B; no pain, no oral opioids • Gr 3 (n=19) KPS B; pain, no oral opioids • Gr 4a (n=31) KPS B; pain, stable doses of opioids: median 120 mg (25-420) • Gr 4b (n=21) KPS B; no pain, stable doses of opioids: median 40 mg (20-180)

  9. Paced auditory serial addition task • Only T 2.4 and 2 s • Only 55% able to perform • Opioid vs NOT: N.S. • Pain vs NOT: P=0.022

  10. Cancer patients: Pain + Opioids: driving simulatorVainio & al. Lancet 1995;346:667

  11. Cancer patients

  12. Neural function tests

  13. Neural function tests

  14. Driving simulator test • M 30: matrices test for nonverbal basic intelligence • Q1: test of capacity for attention • LL5: concentration and structuring ability • SET 3: fluency of motor reaction • PVT: peripheral vision test

  15. Driving simulator test

  16. Driving simulator test

  17. Plasma concentrations

  18. Visual tracking

  19. Non-Cancer pain: Pain + Opioids vs cerebrally compromised patientsoff-road driving evaluationGalski T & al. J Pain and Symptom Manage 2000;19:200-208

  20. COAT (n=16) Age 48.4±11 years Pre-driver evaluation Simulator evaluation Behavioural observation Cerebrally compromised Historical controls of comparable age, same tests and then ... 162 passed, 165 failed the on-road behind-the-wheel evaluation Chronic non-cancer pain + opioids vs cerebrally compromised patients

  21. Chronic non-cancer pain + opioids vs cerebrally compromised patients • COAT-patients outperformed the cerebrally compromised patients (pass/fail) • COAT-patients had greater difficulty in following instructions and • a tendency towards impulsivity

  22. Non-Cancer pain: Pain + Opioids vs acute benzodiazepine/alcohol/sleep deprivation/healthy controlsoff-road driving evaluationStrumpf M & al. Schmerz 1997;11:233-240

  23. Chronic non-cancer pain + opioids vs benzodiazepine/alcohol/sleep deprivation/healthy controls • Gr 1 = Chronic pain + morphine 50-200 mg/d • Gr 2 = premedication with ca-clorazepate 0.3 mg/kg p.o. • Gr 3 = coworkers with blood alcohol levels of about 0.08% • Gr 4 = coworkers on call with < 4h of uninterrupted sleep • Gr 5 = healthy drug free volunteers

  24. Methods • Driving simulator • Questionnaire for mental condition • Vigilance • ”d11” letter cancellation test

  25. Results • Reaction time to breaking: Gr 1-3> Gr 5* • Time to breaking on the hillside: Gr 2> Gr 1, 3-5** • Mistakes: Gr 1: 1.1 • Gr 2: 1.6 • Gr 3: 2.7 • Gr 4: 1.5 • Gr 5: 0.6

  26. Non-Cancer pain: Pain ± Opioids vs matched controls: on the road - behind the wheelKalso E, Heiskanen T, Warjus L & Summala H (still in progress)

  27. Driving in real life:study design • Patients with chronic non-cancer pain needing opioid treatment, driving licence • age 47 years (37-56) • mean VASpi before opioid 5.7 (4-8) • mean VASpi while on morphine 2.9 (0-8) • mean daily dose of SR morphine 180 mg (60-390) • Matched healthy controls • Driving before opioids and after one month on a stable dose (same interval for the control)

  28. Measurements: laboratory • reaction time • time estimation • ”tapping” • synchronisation • visual search • vision • accuracy • field • contrast sensitivity

  29. City driving: city centre and suburb speed at crossings slowing when a pedestrian steps in front of the car checking traffic coming from the right speed profile an experienced driving instructor’s assessment getting lost EEG, EKG Highway driving time spent looking at the road, rear view mirror, keyboard tapping (additional task) lateral movements of the car EEG, EKG Measurements: on the road

  30. Suburban Additional City Center Motorway Motorway 13 - 20 min 25 - 37 min 23 - 28 min 12 - 16 min 9 - 11 min 33 min - 1.1 h EOG EKG EEG 4 times the Monotonous Number Monotonous 3 times the same route/ driving tapping and driving same route/ 15 crossings naming tasks 13 crossings Visual search Vigilance Visual search Vigilance Divided and driving and driving attention speed when speed when approaching approaching a crossing a crossing

  31. City without morphine the patients drove faster at the end of the test no difference in reactions to pedestrians patients looked at the rear view mirror more often compared with controls the patients checked the traffic from the right more often when on morphine Highway no difference in time spent looking at the keyboard patients looked at the rear view mirror more often compared with controls Results

  32. Approaching an unmarked crossing: Speed km/h 28 Control: City centre 27 26 Patient: City centre 25 24 Control: Suburban area 23 22 Patient: Suburban area 21 1 2

  33. Approaching an unmarked crossing: Checking traffic coming from the right 1.00 .98 .96 Control: City centre .94 .92 Control: Suburban area .90 Patient: City centre .88 .86 Patient: Suburban area .84 .82 1 2

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