Last week, while speaking at the National Rx Drug Abuse & Heroin Summit in Atlanta, National Institutes of Health Director Francis Collins announced a plan to help improve pain management in the United States. Specifically, he hopes to expedite research into safe, effective pain medications to help address the opioid abuse epidemic now blanketing the country. As many clinicians now know, the numbers are shocking: On average, prescription opioid analgesic and heroin overdoses kill nearly 100 Americans a day. "Our list of options is woefully short," said Collins.
There are signs that at least in some cities, counties, and states, things may be improving, as health care providers, patients and policymakers take steps to address opioid abuse and misuse. Stricter prescribing laws have been enacted. Doctors appear to be overall prescribing fewer opioids. Yet the role of opioid-based pain management is as contentious a topic as ever, and curtailing opioid prescribing brings with it new clinical questions—including what treatments to turn to instead, and how to prevent some patients from seeking out alternative, more dangerous opiates, such as heroin.
Roger Chou, MD is a professor of medicine at Oregon Health & Science University who studies pain management and how to address opioid misuse. Last year, he served as one of the lead authors on the Centers for Disease Control and Prevention (CDC) guideline on chronic pain; he also has served as director of the clinical guidelines program for the American Pain Society. In addition, Dr Chou is involved in collaborative initiatives with the American Academy of Addiction Psychiatry (AAAP) that are designed to educate clinicians on safe and effective pain management; one such initiative is the Providers' Clinical Support System for Opioid Therapies (PCSS-O), funded by the Substance Abuse and Mental Health Services Administration.
Medscape recently spoke with Dr Chou about his efforts to help address the opioid epidemic, and what role these medications should play in chronic pain management.
Medscape: Hello, Dr Chou. Let's get right into it: Do you personally feel opioids have a role in chronic pain management?
Dr Chou: Yes, I do. But I think the role should be more limited than it has been in the past. I don't think we have a great understanding of the limitations of opioids in terms of effects on pain and improvement in function, and we know a lot more now about the serious harms associated with them, including overdose, addiction, and death. People vary in their response to opioids, as well as in what kind of side effects or risks they experience. There's a lot of individualized decision-making that needs to occur.
I think that lower doses of opioids may be appropriate in selected patients. We do need to be more cautious about who we prescribe opioids to. And we need to be better about how we monitor and manage them, and how we mitigate their risks. This includes being sure that we're doing regular urine drug screens and using information from our prescription data monitoring program, giving people such things as naloxone, avoiding high doses, avoiding benzodiazepines—all of the things that we talk about in the CDC guideline, as well as in the PCSS-O materials.
Opioids are what I would consider an adjunctive treatment. Everything we know about pain is that this is a complex biopsychosocial phenomenon, and that we need to address the psychosocial contributors to pain. One of our big goals should be to get people more functional. Unfortunately, giving somebody a pill doesn't do this the vast majority of the time.
We need to be using active treatments. These are typically nonpharmacologic therapies, such as exercise therapy, cognitive behavioral therapy, some mind/body interventions—interdisciplinary rehab that actively engages patient in their care, by focusing on coping strategies, movement, and improvement in function. Then, if we need to, we may consider opioids as an adjunct. Again, not everybody is appropriate for opioids, and we do need to be more selective about how we use them.
Medscape: Do you think opioids can ever be a long-term solution for patients?
Dr Chou: Ideally, we would eventually get most patients off of them. However, in reality, the properties of opioids—the fact that people get physically dependent and develop a tolerance on them—make it very difficult. The data do tell us that somebody who's been on opioids for more than 6 months or 1 year are likely to be on them for many years.[2,3] It's difficult to get patients off of opioids. We need to be very careful about how we use these. I don't think there's anything inherently wrong with maintaining somebody on low doses of opioids, as long as it's doing what it's supposed to in terms of helping their pain and function and not causing harm. But yes, ideally we could taper people off once we help them understand coping strategies—and once other factors that contribute to pain are managed, such as depression and sleep problems.
There are some pain doctors who are very aggressive about tapering opioids and using nonpharmacologic and nonopioid therapies, which are actually quite successful. But for many primary care docs, this is still a big challenge. But we're trying to get there, trying to understand how to use these nonopioid therapies better.
A big part of this, of course, is getting better access to all of these treatments. It can be very difficult in many places, including my own, to access adequate psychological care and interdisciplinary rehab. All of these things that we think are good alternatives can be difficult to access and get reimbursed for. There are a lot of challenges there.
We are starting to make some progress. We've started to see some of the overdose data and prescribing rates shift down. On the other hand, we have seen a bump in the use of illicit opioids, which we think is related in part to people who develop opioid use disorder for prescription opioids. So there's multiple things going on simultaneously. It's a matter of addressing both sides of this. We have to deal with chronic pain better, including how we use opioids, and we also have to be better at identifying opioid use disorder and in treating and managing it.
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Cite this: The Evolving Role of Opioids in Managing Chronic Pain - Medscape - May 01, 2017.