Bret S. Stetka, MD

Disclosures

December 10, 2015

In This Article

Why Opioids Belong in Chronic Pain Care

On Monday, November 9, 2015, at the American College of Rheumatology (ACR) annual meeting, a neurologist and a rheumatologist took the stage to debate whether or not opioid analgesic medications belong in the management of chronic, noncancer pain.[1] John Markman, MD, a neurologist at the University of Rochester Medical Center, took the pro position; Daniel Clauw, MD, a professor of anesthesiology, rheumatology, and psychiatry at the University of Michigan, argued against opioid use in certain patients. Speakers were each given 15 minutes to argue their side, as well as a 5-minute rebuttal each.

Dr Markman started things off: "Opioids," he began, "are tools, like a car. Or like an Uber here in California. Or a gun. As such, they can be used well, or they can be used in ways that are dangerous. When used properly, they can be incredibly helpful."

Despite the session's title—"Opioids for the Treatment of Chronic Non-cancer Pain... Use or Abuse?"—Markman feels it doesn't make any sense to be either "for" or "against" opioids, given that the issue of whether or not their benefits outweigh their harms—or vice versa—simply isn't that black and white. From his perspective, the bigger question is: "Which patients will benefit from this class of therapy, and which won't?"

Markman commented that pain management is a major priority for patients with rheumatoid arthritis and reviewed the evidence supporting opioid therapies, citing the fact that there have been over 60 randomized controlled trials for the drug class in chronic noncancer pain over the last 20 years or so. About one half of these, according to Markman, included follow-up of 1 year or longer; and overall they suggest that opioids demonstrate broad-spectrum efficacy across neuropathic pain, acute pain, and chronic musculoskeletal pain.

"One area of debate that is raging in my field, and yours as well," he continued, "is whether or not there is a dose-dependent risk with opioids." He then presented findings from a 2003 paper[2] by Rowbotham and colleagues published in the New England Journal of Medicine showing that in 81 patients with central or peripheral chronic neuropathic pain, there was an analgesic dose-dependent benefit. "This is a very important point because, as you know, in the US there are legislators, insurers, and other institutions that are looking to cap the maximum dose of opioids per day," he said.

The current standard of pain care is multimodal analgesia, and Markman feels that if clinicians aren't including opioids as one option, they're doing at least some of their patients a disservice.

Next Markman revealed that one of the points that he and Dr Clauw were tasked with discussing was the role of opioids for chronic central pain syndrome. "I have fished in these waters for 20 years, and I have no idea what chronic central pain syndrome is," he admitted, "It's sort of like coming to the ACR meeting and saying joints that are red, hot, and swollen are all red, hot, and swollen in the same way." Markman feels that the notion that there is a single chronic central pain condition is far too reductionist and an oversimplification.

Though a supporter of opioid analgesics in certain patients, Markman is well aware of the risk associated with these agents. "Opioid abuse is a colossal problem in the US at the moment," he commented, flashing a graph showing a sharp rise in opioid use starting in 1997. It was around this time, he recalled, that a marketing plan for long-acting opioids was launched, one that portrayed the agents as safe.

"Ultimately this was a settled case with the government because that wasn't true, and it led us down a 20 year slippery slope to what has turned into a devastating issue for our country," said Markman. "Forty people will die today due to opioid-related complications, and 40 will die tomorrow. It's a small plane crash every day. But it doesn't negate the value of these drugs for people who have chronic pain."

Markman concluded by emphasizing how important it is to risk-stratify patients; to inquire about risk factors for abuse, misuse, and diversion, including a history of abuse or a history of abuse in a family member, and what their other habits are.

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