COMMENTARY

Conflating Effective Chronic Pain Management and Opioid Abuse Potential

Charles E. Argoff, MD

Disclosures

April 14, 2017

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My name is Dr Charles Argoff, and I am professor of neurology at Albany Medical College and director of the Comprehensive Pain Management Center at Albany Medical Center in Albany, New York. The comments that I am about to make reflect my own personal opinion regarding the subject matter.

Appropriate, meaningful, and compassionate treatment options for tens of millions of Americans with persistent chronic pain have come under significant scrutiny in the past few years in the face of our nation's deepening concerns with rising opioid abuse rates. As a physician who is American Board of Medical Specialties certified in neurology and in pain management, I focus on prescribing safe, responsible, and effective treatments for people who are experiencing severe chronic pain. In that context, I am increasingly concerned that policymakers and prescribers are conflating two different and critically important issues.

Addressing the treatment needs of people experiencing severe chronic pain and addressing real concerns regarding the abuse and misuse of various controlled substances, including opioids, are being conflated to such an extent that, as a result, the concept of undo harm to people in pain is becoming the new standard of care due to the sudden cessation of treatment that had previously been efficacious. This is clinically unacceptable.

The foundation of the accepted standards of medical practice is based upon offering appropriate treatment in as safe and effective a manner as possible. When clinicians are able to choose among multiple treatment options for any medical condition, the safest options are meant to be prioritized over those that are less safe. This principle of medical practice is extremely relevant to pain management. Tens of millions of people experiencing severe chronic pain do not experience sufficient relief from multiple nonopioid therapies. These include complementary approaches, rehabilitation approaches, nonopioid pharmacologic approaches, as well as interventional therapies including injections, spinal stimulation, or even intraspinal analgesic approaches.

For these tens of millions of people experiencing severe chronic pain, who have not benefited from nonopioid therapies, chronic opioid therapy may be a safe and effective treatment approach. Thus, appropriate access to such treatment is necessary, recognizing that all prescribed and over-the-counter medications carry risks and that we need to focus on the availability of all types of medications that are as safe as possible. Patients prescribed opioid analgesics—both immediate release (IR) and extended release (ER)—should only be prescribed the safest available agents.

What is the state of available opioid analgesics? Currently, multiple opioid analgesic preparations, including multiple distinct opioid chemical entities, can be prescribed. This is vital to optimizing patient care. As is true with various nonsteroidal anti-inflammatory agents, statins, and certainly with medications used to treat diabetes, while one compound may be effective for some patients, a different compound may be best for others. This underlies, with respect to opioid therapy, the concept of opioid rotation and highlights the need to have multiple opioid analgesics, including oxymorphone, available to most effectively utilize this class of analgesics to treat chronic pain. Yet, currently available opioid analgesics even of the same chemical ingredient are not equal.

Safety enhancements have been made to certain but not to all preparations. The US Food and Drug Administration (FDA) has designated specific opioid formulations as having abuse deterrent properties. Other formulations have been developed to provide greater safety, but the FDA has not designated them as meeting the standards for receiving an abuse deterrent label. However, what cannot be overlooked is that there are multiple additional IR and ER opioid formulations that have not been manufactured to enhance safety in any specific way.

Again, we cannot overlook that there are multiple IR and ER formulations that have not been manufactured to enhance safety in any specific way. Shockingly, the prescriber too often does not have full control of what preparation his or her patient picks up at the pharmacy. We need to find a path to ensure that all opioids, both IR and ER, are armed with abuse deterrent properties. Equally important, we need to ensure that physicians as well as other prescribers, understand these benefits.

The reality is that for millions of people with chronic pain, opioid therapy is effective and safe in helping them to live more comfortable and productive lives. Let me say that again. The reality is that for millions of people with chronic pain, opioid therapy on a chronic basis is effective and safe in helping them to live more comfortable and productive lives. This is true even in the absence of abuse deterrent formulations for all opioids and for all prescriptions, but we can and must do even better on three fronts.

First, we must maintain the availability of multiple specific opioid analgesics to meet the specific and personalized needs of the people we treat who, without such availability, would suffer unnecessarily. Second, we must take actions that meaningfully incentivize the development of the next generation of abuse deterrent formulations. Third, we must ensure that those experiencing severe chronic pain, for whom chronic opioid therapy is an appropriate treatment option, have access to the safest medication options currently available.

In summary, conflating appropriate and effective opioid use with opioid abuse and harm will neither help those who benefit from chronic opioid therapy to be optimally treated, nor will it sufficiently address the disease of addiction, as well as the harms associated with opioid abuse and appropriate treatment for such. Thank you.

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