Opioid Therapy for Chronic Pain:  Where to Draw the Line?

Nancy A. Melville

June 29, 2017

PITTSBURGH — Better across-the-board physician and patient education about the risks and benefits of opioids for chronic pain is key to stopping the US opioid epidemic, experts say.

"All physicians have to deal with chronic pain patients, and they need a basic understanding in pain management. [These] efforts can't just focus on how to write opioid prescriptions safely, we have to teach people how to do proper pain management and it has to be more global, including consideration of alternative treatments," said Ed Michna, MD, JD, Brigham and Women's Hospital and Harvard Medical School and director of the Pain Trial Center, Boston, Massachusetts. Dr. Michna was featured in a debate about opioid prescribing here at the American Pain Society (APS) 2017 Annual Scientific Meeting. 

But whether nationwide prescriber education on opioid use should be mandatory is a highly contentious issue, said panel member Douglas Gourlay, MD, director of the pain and chemical dependency division of the Wasser Pain Management Centre at Mount Sinai Hospital in Toronto, Ontario, Canada.

"I've always felt education is a far better way to control things than regulation, but it's a contentious point and you need a minimum amount of regulation that provides a framework for this to work," said Dr Gourlay.

"The idea that you learn enough in medical school or in residency to [prescribe opioids] safely is obviously not true. I think however we get education to clinicians, we need to do it carefully."

Among key challenges is being able to say no to patients when necessary, Dr Gourlay said.

"One of the biggest problems is that it takes 30 seconds to say 'yes' [to prescribing an opioid] and 30 minutes to say 'no'," he said.

Likewise, proper education of patients is equally critical, experts agreed.

"The ounce of prevention of educating patients on what to expect will save you months of agonizing work with patients coming back," said session moderator David Tauben, MD, chief of pain medicine, University of Washington in Seattle.

Dr Michna agreed. "I think setting realistic expectations with patients is the most critical thing, yet it's the one thing that is rarely ever done, particularly in an acute setting. Surgeons don't even ask about prior history of substance abuse and then the patient gets into trouble and then the problem is dumped on PCPs [primary care physicians] and other specialists. You need to know about the patients you're operating on and then set realistic expectations in their treatment with opioids," he said.

Greater Caution Warranted

Jane Ballantyne, MD, professor of anesthesiology and pain medicine at the University of Washington, argued for greater precautions with opioid prescribing for chronic pain and detailing the many known risks, including misuse, abuse, and death, in addition to risks related to high doses, such as falls and fractures in the elderly and a lower likelihood of returning to work.

Regarding analgesic efficacy, controlled trials are too time limited to make any determination about long-term efficacy, and anecdotal reports don't tell the whole story, she said.

"Patient and prescriber anecdotal reports are influenced by opioid dependence. I mention that because I think it's a very important component," she said.

She underscored the need to develop strategies to prevent the known brain changes that occur with the continuous use of opioids — either short or long term — around the clock, spurring a cycle of analgesic tolerance and dependency similar to the cycle seen with addiction.

"In the addiction world, the drugs are no longer being taken to get the euphoria but to avoid the bad effects of withdrawal, and with chronic pain, patients need to continue to take the drugs to avoid withdrawal and the worsened pain that goes along with it. If, instead, we only used short-acting drugs occasionally, it could possibly help prevent these brain adaptations."

In addressing the central debate question of where to draw the line, Dr Ballantyne emphasized starting with the identification of patients with chronic noncancer pain, for whom opioid use is generally considered not to be helpful.  

As described in a 2014 position paper of the American Academy of Neurology, those should include the common conditions of acute low back pain with no pathoanatomic diagnosis, headache, and fibromyalgia, she said.

In identifying the most suitable candidates, she suggested carefully considering those who truly have few other options and treatment with the goal of providing comfort.

"One concept that I like is the idea that if you are prescribing opiate treatment to provide comfort, and not to provide function and normal quality of life in a younger person, then it is a reasonable choice," Dr Ballantyne said.

"If the underlying cause of pain is disabling, then maybe that person's a candidate, if they cannot be improved by primary disease treatment or lifestyle changes, and if other treatments are not possible, for example an elderly person who cannot tolerate other options, such as exercise or nonsteroidals."

Lower opioid doses, as are increasingly being recommended in various states, also represent a place to draw the line in opioid prescribing. A nother consideration should be the estimated risk when prescribing , such as the higher risk among younger people for misuse or dependency compared with the risk among  older patients .

Overall, however, the multitude of safety concerns that have led to the opioid epidemic underscore the balance of risks over benefits, Dr Ballantyne said.

"If you look at risk/benefit analysis, it will rarely favor benefit over risk."

In his counterargument, Dr Michna made the case that increasingly rigid laws and policies on long-term opioid prescribing for chronic pain often fail to address the needs of patients with chronic pain who do benefit from the treatment and do not misuse the drugs.

No Evidence of Long-term Benefit

He described several cases of patients with chronic pain benefitting from the long-term treatment, including an obese woman in her 30s with fibromyalgia who experienced such significant pain reduction with opioids that she became physically active and was able to lose more than 250 pounds.

Regarding a lack of evidence on any benefits of long-term opioid use in chronic pain, Dr Michna noted that evidence is also lacking on the benefits of other medications, including nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs have minimal analgesic effect for chronic pain conditions, such as low back pain and osteoarthritis.

"The paucity of evidence for long-term effectiveness is true of pain treatments in general. Why force people off of opioids when they are satisfied with the effect and using the drugs appropriately?" he said.

Dr Michna cited a recent editorial  by Kurt Kroenke, MD, and Andrea Cheville, MD, published in JAMA, which argued "the movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an overreaction."

He agreed with the paper's assertion that "imperfect treatments do not justify therapeutic nihilism."

"All I'm asking for is a rational approach. It's all about individualization of care. Why don't we have well-educated physicians and well-informed patients make the decision about their care?" said Dr Michna.

The most definitive solution, said panelist David A. Fishbain, MD, professor of psychiatry and behavioral sciences and adjunct professor of neurological surgery and anesthesiology at University of Miami Health Sciences, Florida, would be the development of a painkiller that doesn't cause dependency.

"The next biggest advance will be an opioid that doesn't have any addictive properties, and then this whole issue will be settled," he said.

Dr Gourlay has served as an advisor or consultant to Purdue Pharma, Titan Pharmaceuticals, Organon-Ligand, Alpharma, and Janssen-Ortho Inc. Dr Michna disclosed that he has previously consulted and performed funded research for "almost all" pharmaceutical companies in pain medicine , but currently has no relationships. Dr Tauben, Dr Ballantyne, and Dr Fishbain have disclosed no relevant financial relationships.

American Pain Society (APS) 2017 Annual Scientific Conference. Presented May 20, 2017.

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