Opioids for Noncancer Pain a Subject of Hot Debate: An Expert Interview With Pain Specialist Ajay Wasan, MD, MSc

Thomas R. Collins

February 17, 2010

February 17, 2010 — Editor's note: High-profile celebrity deaths linked to opioid use are garnering much media attention, and there are a number of news reports of governments cracking down on pain-medicine clinics. As a result, the use of opioids for noncancer pain is being hotly debated by pain medicine specialists and was a topic at the recent American Academy of Pain Medicine (AAPM) 26th Annual Meeting, held February 6–10 in San Antonio, Texas.

Medscape Neurology interviewed AAPM cochair Ajay Wasan, MD, MSc, associate professor in the Department of Anesthesiology and Psychiatry at Harvard Medical School in Boston, Massachusetts, and moderator of Opioid Therapy: Examining and Evaluating the Pros and Cons of Oral and Intrathecal Opioid Therapy in the Treatment of Non-Cancer Pain.

Medscape: Why did you choose to have a debate session on the pros and cons of opioid therapy in the treatment of noncancer pain?

Dr. Wasan: We had a 160 people or so [in the audience]. About 20% of the entire AAPM meeting was there in that 1 session. . . . One reason we have several debate sessions is that it's a bit of a different format for presenting a lot of information in a different type of learning environment, a little more provocative, maybe a little more entertaining, where people are making a bigger effort to communicate the key points. So I have several debate sessions laid out in that way. I also was a high-school and college debater and a debate judge in high school and I love seeing debates.

Medscape: The vote on pro-opioid or anti-opioid use was a split, really. What did that tell you about this issue?

Dr. Wasan: It tells you it's controversial and it tells you that you can really look at good information in many different ways and decide which information is more important than which. Because there's good evidence on both sides, good arguments can be made. So the vote really illustrates that this is what they mean when they say something is controversial. Some of it is taking good data and interpreting it differently. But on some of it, there just aren't good data, so what do we do?

Medscape: What does the literature show about the efficacy of opioid therapy on noncancer pain?

Dr. Wasan: This is really why we had the debate. I think the biggest take-home message is that opioids can be useful in carefully selected patients, where careful decisions are made about what to prescribe and the amounts to prescribe. But there's so much evidence to suggest that that just doesn't happen.

The reality is you don't have that much data on the nature of subgroups of responders to opioids, who's going to get good analgesia and who is not — we have a little bit of data but not enough — and who is going to use opioids properly and who is going to abuse them.

If you give them to everybody, you're going to have problems that may outweigh the benefits. But if you're more careful about how you prescribe, there may be fewer problems. We just don't have enough of the data to know that.

Medscape: What are the pain-medicine community's best ideas for deterring opioid abuse?

Dr. Wasan: One of the best ways is to have careful selection of patients, trying to understand who is more likely to abuse and who is less likely to abuse. There are several tools available, strategies available, to screen the patient at the level of their medical condition. For instance, cancer pain is very likely to respond well, while certain other conditions, such as chronic headaches and fibromyalgia, don't respond as well. You've got to look at the medical condition and look at the patients. Do they have a history of drug abuse? Do they have a history of legal problems? Do they have significant depression or anxiety? Those all predict opioid misuse.

Medscape: Do you believe there is sufficient use of basic strategies, such as psychological interviewing, to predict the potential for opioid abuse?

Dr. Wasan: No. That's a huge problem, that there isn't enough use of those techniques. The point to be communicated is that it's not even a specific psychological interviewing technique. It's a few simple basic questions that physicians are trained to ask as part of a detailed history, such as a family history of substance abuse, a patient's history of substance abuse. . . . You don't have to be a psychologist to ask these questions. In fact, if you use some of the surveys — such as the Opioid Risk Tool and the Screener and Opioid Assessment for Patients with Pain (SOAPP) — and you combine that with looking at the items and seeing what's checked, and then ask the patient, "What is this? Have you had any history of problems? What is the problem?" — you actually have a very complete psychological profile. You don't have to be a psychologist to do this stuff.

Medscape: Why isn't a psychological assessment done more often for the patient in need of opioid medication?

Dr. Wasan: It needs to be done more and more and more. In fact, the [district attorneys] have made it very clear. The Federation of State Medical Boards guidelines to opioid prescribing say you really need to understand this propensity for misuse before you prescribe.

There's no doubt that the profession is changing, and it's a moving kind of target. But people are striving for [a better understanding of the patient who presents with pain]. Physicians are starting to do it, but it's probably not as widely adopted as it should be at this point.

Medscape: Last, do you have any predictions on the future of opioid use for noncancer pain?

Dr. Wasan: Unfortunately, the pendulum has swung, I think, too far one way, where pain-medicine organizations and specialists have been pushing almost the indiscriminate use of opioids for chronic noncancer pain. I think we're taking a step back from that. There are, unfortunately, some people who want to swing the pendulum totally the opposite way. But most people are at least saying, "Wait a second, we have some information, more information now, to do more rational prescribing." So I think both in pain medicine and primary care there'll be more attempts at rational prescribing. My fear, though, is that patients who may be appropriate won't be prescribed opioids because of so many fears about addiction and abuse without making an effort to understand who's more likely to misuse their opioids and who is actually more likely to follow the rules.

Dr. Wasan reports receiving speaking honoraria from Alkernes, Eli Lilly and Company, and Medtronic Inc.

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