Expert Panel Final Report on Opioids in Chronic Pain

Pauline Anderson

January 13, 2015

Identifying conditions for which opioid use is most appropriate, the optimal regimens for these conditions, and the best alternative for patients unlikely to benefit from opioids are key challenges in the field of chronic pain management, an independent expert panel convened by the National Institutes of Health (NIH) concludes.

During an NIH workshop in September 2014, the multidisciplinary panel identified key evidence gaps and research priorities for long-term opioid use. An abridged version of the panel's report is published online January 13 in Annals of Internal Medicine, along with, in a separate publication, a summary of a review of the current evidence, also reported by Medscape Medical News.

The Pathways to Prevention workshop was cosponsored by the NIH Pain Consortium, the National Institute on Drug Abuse, and the National Institute of Neurological Disorders and Stroke. The evidence report was prepared by the Pacific Northwest Evidence-based Practice Center through the Agency for Healthcare Research and Quality's Evidence-based Practice Centers Program. The panel's report is independent, not a policy statement of the NIH or the federal government, an NIH statement notes.

The panel called on federal and nonfederal agencies to sponsor research into various aspects of pain management and opioid use. One of the most important first steps should be to harmonize guidelines of various professional groups, the report's lead author, David Reuben, MD, chief, Geriatric Division, and professor, medicine, University of California, Los Angeles, told Medscape Medical News.

Dr David Reuben

At the root of the problem is the gap in knowledge about the best approaches to treating chronic pain, said Dr Reuben. "We don't know enough about who benefits from opioids and who doesn't, about who gets pain relief and who gets into trouble with adverse effects from these drugs."

The Right Hammer

It's also not clear which pain types respond to opioid therapy, he said. "There are many different kinds of pain and some pain perhaps responds better than others," said Dr Reuben. "There's a huge gap in knowing which is the right hammer for the right nail."

Another important research priority is learning what therapies work for patients who don't benefit from opioid therapy, he added.

"A lot of this takes time, and it takes a team, and it takes other kinds of modalities and those just aren't available," said Dr Reuben.

Optimizing opioid use can also be cost-effective, he stressed. "People are suffering with pain, and people are losing their jobs because of pain, and, conversely, people are dying because of opioid treatment when they shouldn't be getting opioid treatment. Those failures to provide optimal treatment are all very expensive and if those costs can be used appropriately in the healthcare system, it could be cost-neutral or cost saving, and it would certain save a lot of morbidity."

Dr Reuben said he wants the new report to become "a call to action" and the issues it discusses to be become a priority.

Workshop delegates heard that chronic pain affects an estimated 100 million Americans or a third of the US population. About 25 million have moderate to severe chronic pain that limits activities and diminishes quality of life. Pain is the main reason Americans receive disability insurance.

Experts estimate the societal costs of pain at $560 billion to $630 billion per year in the United States due to missed workdays and medical expenses.

To manage pain long term, some 5 to 8 million Americans depend on opioids. The number of opioid prescriptions for pain treatment has increased dramatically in recent years — from 76 million in 1991 to 219 million in 2011.

Physicians Ill Prepared

The opioid prescription problem extends beyond issues around medical treatment. Opioids are finding their way illicitly into the public arena, according to the report. The Substance Abuse and Mental Health Services Administration's 2013 National Survey on Drug Use and Health found that among those aged 12 years or older who were abusing analgesics, 53% reported receiving them for free from a friend or relative.

Such use is taking its toll. From 2000 to 2010, the number of hospitalizations for addiction to a prescription opioid increased more than 4-fold to more than 160,000 per year. In 2010, one of every eight deaths among those aged 25 to 34 years was opioid related.

The increase in opioid prescriptions, together with the parallel jump in opioid overdoses and treatment for addiction to prescription painkillers, has created what the authors called a "silent epidemic."

When it comes to managing patients with legitimate pain conditions, physicians have little training. Clinicians, said the panelists, "are often ill-prepared to diagnose, appropriately assess, treat and monitor patients with chronic pain."

The experts identified several important management issues for clinicians. "First, they must recognize that patients' manifestation of and response to pain will vary, with genetic, cultural, and psychosocial factors all contributing to this variation," they said.

Some physicians believe that patient expectations for pain relief are unrealistic. They're sometimes quick to label patients as "drug-seeking" or "addicts," and some even "fire" patients for merely voicing concerns about their pain management, the report notes.

"A more holistic approach to the management of chronic pain that is inclusive of the patients' perspectives and desired outcomes should be the goal," they write.

But physicians don't have much to go on when it comes to making clinical choices. The panel found the lack of evidence for every clinical decision that a provider needs to make about the use of opioids for chronic pain particularly "striking." There are few data, for example, to help providers select specific agents, titration schedule, or dose-tapering strategy. Also, use of opioid rotation has not been formally evaluated, and opioid conversion tables lack consistency.

Although the US Food and Drug Administration now includes data in package inserts to help clinicians switch between opioids, many clinicians and pharmacies "seem to be unaware of this," said the panel.

Patient Evaluations

According to the panel, initial patient evaluation should appraise pain intensity, functional status, and quality of life, as well as assess known risk factors for potential harm (including history of substance use disorders; current substance use; presence of mood, stress, or anxiety disorders; medical comorbidity; and concurrent use of medications with potential drug-to-drug interactions).

As well, said the authors, it seems "reasonable" to incorporate clinical tools, such as prescription drug monitoring programs, into the assessment, although these are not well studied.

During the workshop, speakers stressed the need to include a range of treatment approaches that might initially include nonpharmacologic options, such as physical therapy, behavioral therapy, and complementary and alternative medicine, followed by pharmacologic options that include nonopioid pharmacotherapies.

Attendees heard that the type of pain could influence pain management approaches. Patients with more peripheral nociceptive pain, such as acute pain due to injury, rheumatoid arthritis, or cancer pain, may respond better to opioid analgesics, while those with central pain syndromes, such as fibromyalgia and irritable bowel syndrome, may respond better to centrally acting neuroactive compounds (eg, certain antidepressant medications and anticonvulsants).

The report highlighted the potential harms of opioid use, including falls and fractures, hypogonadism with resultant sexual dysfunction, and myocardial infarction. It also stressed the lack of data on whether risk mitigation strategies, such as patient agreements, urine drug screening, and pill counts, are of any benefit.

Because pain affects physical, emotional, and cognitive function, as well as interpersonal relationships and social roles, managing pain requires a multidisciplinary approach similar to that recommended for other chronic complex illness, such as depression, dementia, eating disorders, or diabetes. Unfortunately, said the panel, team-based approaches in this area have largely been abandoned in favor of primary care providers managing pain alone.

"In the case of pain management, which often requires substantial face-to-face time, quicker alternatives have become the default option," they write. "As a result, providers often prescribe opioids for pain even when other methods might be safer and more effective."

Payment structures may facilitate this excessive opioid use, the report notes. Current reimbursement patterns may be inadequate to reflect the time and approaches needed to adequately treat pain conditions. As an example, panel members cited formulary restrictions that require evidence of failure of multiple therapies before nonopioid alternatives are covered.

Report authors stressed the "clear need" for well-designed longitudinal studies of the effectiveness and safety of long-term opioid use in patients with chronic pain. These, they said, would need to be large and therefore expensive.

Panel Recommendations

Among the panel's recommendations is one to synchronize guidelines of various professional organizations "so that everyone is speaking with the same voice," said Dr Reuben.

Other recommendations seek to "lay the fundamentals" for what needs to change in the health system, including testing new care models. "There have been some really interesting models with dementia and depression that include multidisciplinary, multidimensional approaches that seem to have worked very, very well," commented Dr Reuben.

Incorporating elements of pain management decisions into electronic health care records is another recommendation that could be an early step in fixing what ails the current system, said Dr Reuben.

Other recommendations, for example, those calling for more research on the biological mechanisms of pain, will take more time, according to Dr Reuben. He said he hopes the report pushes the issue of opioid research into a priority position in terms of funding from the NIH.

Dr Reuben has disclosed no relevant financial relationships.

Ann Intern Med. Published online January 13, 2015. Abstract

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