Opioids for Chronic Pain: Guidelines Discourage It But Clinicians Find Value

Opioids for Chronic Pain: Guidelines Discourage It But Clinicians Find Value

Although numerous participants in a recent landmark study sponsored by the National Institutes of Health (NIH) found no solid evidence to support long-term use of opioids for chronic non-cancer pain, tens of thousands of patients across the country swear that opioid painkillers are the only treatment that helps ease their intolerable chronic pain. As well as the NIH study participants, the American Academy of Neurology (AAN) and many other professional associations all say that evidence shows the risks of opioids far outweigh their benefits for conditions such as headache, lower back pain, fibromyalgia and other chronic non-cancer pain.

The NIH study has sparked the development over the next year or two of a new set of guidelines aimed at reducing what many see as the recklessness of opioid prescribing in America. But many doctors continue to prescribe opioids for chronic pain because they see no effective alternatives. And when they try to ease off the opioids to get more in line with new guidelines, patients are simply left suffering - and that's intolerable to most doctors. The AAN statement lists several 'best practices' for prescribing any opiates. Their guidelines include verifying patient legitimacy and history through the state's prescription data monitoring program (if one exists) before prescribing opioids. The AAN guidelines also say primary care doctors should refer chronic pain patients to specialists if the patients are on daily doses of 80 to 120 mg morphine-equivalent or more per day. (The strength of opioids/opiates is measured against the strength of the opioid morphine as a baseline. Opiates are derived from opium, opioids are synthetic equivalents.)

What do clinicians have to say about opioids for chronic pain? MedPage Today recently surveyed four noted clinicians across the country for their take on the situation. The survey participants were: James A. McGowan, MD, a pain management specialist at the Center for Interventional Pain Medicine, a part of Mercy Medical Center, in Baltimore; Jack P. Freer, MD, clinical professor, geriatrics and palliative medicine, at the University of Buffalo Department of Medicine in Buffalo, N.Y.; Lewis S. Nelson, MD, professor, Ronald O. Perelman Department of Emergency Medicine at NYU Langone Medical Center in New York City; Sabine Kost-Byerly, MD, associate professor, Johns Hopkins School of Medicine and director, pediatric pain medicine at Johns Hopkins Charlotte R. Bloomberg Children's Center in Baltimore. The editors asked the doctors: What's your view of the official statements, like the AAN's, on the value of opioids for chronic non-cancer pain? When if ever do you prescribe opioids for these patients? Are there particular types of such pain that are more responsive to opioids?

Here are some of their thoughtful responses: James McGowan, MD: "On a whole, the use of chronic opiates over the last 20 years has done nothing to decrease rates of chronic pain in this country and very little to improve the lives of most patients who deal with chronic pain. At the same time, I do believe that some patients can experience long-term improvement in pain control and increased functioning with chronic opiates if these patients are carefully chosen and closely monitored. "We swung the pendulum much too far in one direction with the use of opiates over the last 20 years, but I think we need to be very careful about swinging it too far in the opposite direction and completely abandoning the use of chronic opiates altogether. A balance must be struck in which judicious use of opiates in limited patient populations replaces widespread and unregulated usage." Jack Freer, MD: "In general, the AAN position paper is a thoughtful and useful guide to the use of opioids in chronic non-cancer pain. In practice, however, it may be difficult for physicians to adhere to this kind of rigorous program.

It is time consuming, since it requires an initial abuse risk assessment, individualized treatment contract, and ongoing monitoring with random urine testing. The regular re-evaluation of the treatment effectiveness needs to be function-oriented, and should, almost always, include other modalities (such as physical therapy). "It also requires a physician to 'pull rank' and refuse requests to keep increasing the dose. A practitioner must be prepared to tell a patient (who says that the dose is inadequate), 'maybe this is not the right medicine for your pain.' Many physicians are not prepared to spend this time and energy ... [so they] take one of two easier paths: either they become very loose in their prescribing of opioids, or they stop prescribing them altogether." Lewis Nelson, MD: "The [AAN] guideline better focuses on the safety of chronic opioid therapy, which carries significant risks, including addiction, overdose, and death, even with therapeutic use. In addition, the guideline captures the large public health burden, measured by both addiction treatment and mortality that has paralleled the rise in the use of such therapy." Sabine Kost-Byerly, MD: "Patients may benefit from opioids to facilitate more effective physical therapy but if opioids make them too drowsy to participate, nothing has been gained.

They may also benefit from opioids if recurrent reconstructive surgeries are needed after severe trauma. Pediatric and adolescent patients may receive opioids for weeks and sometimes months in these cases. "It is important for providers to critically assess their patients during this time as it is all too easy for patients to seek the soothing effects of opioids to manage depressive symptoms that may have arisen due to their change in body image or prospects for an independent life. There is nothing wrong with acknowledging such feeling but opioids are the wrong drugs to treat them. " McGowan: "There are groups of patients whom I will sometimes treat with chronic opiates. In general, these are patients in whom I can clearly demonstrate an anatomic source of pain, such as severe arthritis, significant spinal degeneration, or a history of major trauma, as opposed to patients in whom the cause of pain is not easily identified.

I will also consider opiates in patients with medical contraindications to other therapies, such as patients with severe arthritis who cannot take anti-inflammatories because of chronic kidney disease." Nelson: "In the emergency department I care for many patients being treated with chronic opioid therapy for a chronic pain syndrome. Most present for [problems with their pain] but complications related to the use of opioid therapy are a frequent reason as well. Tolerance and hyperalgesia add to the complexity. However, the widespread use of prescription drug monitoring programs has allowed more judicious consideration of opioid use." Freer: "It is difficult to predict which pain will be most responsive to opioids (although some pain is predictably poorly suited - neuropathic pain is the prime example). Conscientious management of chronic non-cancer pain requires a disciplined approach with ongoing reassessment and a transparent but firm relationship with the patient. Prescription drug abuse is an enormous public health problem and physicians must be prepared to take an unpopular stance with some persistent patients." McGowan: "I will usually avoid opiates in patients who seem fixated on opiates as 'the only thing that works' as opposed to those who are open to using other treatment modalities such as non-opiate medications, interventional pain techniques, and physical therapies. I also will generally avoid opiates in patients with history of misuse or abuse of prescription opiates, patients with other significant substance abuse problems, or patients with significant psychiatric issues.

Although there is no 100 percent foolproof way to prevent bad outcomes with chronic opiates, I find that by sticking to these guidelines, chronic opiates can be used for the betterment of some patients." The author of the recent AAN position guidelines, Dr. Gary Franklin of the University of Washington in Seattle, authored a study back in 2005 on the rising trend of prescription opioid-related deaths among workers in the state. At that time, Franklin referenced an important fact of life among many long-term chronic pain patients taking opioids - the often seen phenomenon of opioids increasing pain, the condition called 'hyperalgesia' which Dr. Nelson referred to earlier in this article. In his 2005 study, Franklin said: "The reasons for escalating doses of the most potent opioids are unknown, but it is possible that tolerance or opioid-induced abnormal pain sensitivity may be occurring in some workers who use opioids for chronic pain.

Opioid-related deaths in this population may be preventable through use of prudent guidelines regarding opioid use for chronic pain." That was 10 years ago, and little has changed - in fact, the rates of opioid dependence, addiction and overdose have only increased. But as we can see from the thoughtful comments made by experienced and caring physicians, changes are being made. It appears that American clinicians are confronting the prescription opioid epidemic intelligently, and in the long-term may turn things around.

Here at Novus Medical Detox Center, we've recently expanded our facilities, which will help us deal with the growing numbers of people affected by prescription drugs, including many affected by long-term opioid use for pain that got out of hand. Novus continues to achieve remarkable success helping patients get their lives back, free from the effects of prescription opioids and other drugs. Don't hesitate to call Novus if you or someone you care about is suffering from the effects of drugs or alcohol. We're always here to help.

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