Pauline Anderson

November 01, 2017

SAN DIEGO — Under pressure to curb opioid prescriptions, and with some experts insisting these medications aren't effective long term for chronic pain, clinicians are increasingly reluctant to prescribe them. Yet, according to at least one expert evidence supports their use in particular pain patients.

"The question isn't should or should not healthcare providers prescribe opioids, but rather, how well are we prepared to prescribe opioids for our patients to get the best benefits with minimal risks," Charles E. Argoff, MD, professor of neurology, and director, Comprehensive Pain Center, Albany Medical College, New York, told delegates attending the Academy of Integrative Pain Management (AIPM) 28th Annual Meeting here.

The National Academy of Medicine (formerly the Institute of Medicine) and other health organizations estimate that chronic pain affects more than 100 million US adults. Dr Argoff noted that most healthcare providers currently treat patients who, as a part and in the course of their various medical disorders, experience severe chronic pain.

During his presentation, Dr Argoff noted that not all patients with chronic pain benefit from opioid therapy, just as not all patients with chronic pain benefit from any other specific therapy, medical or otherwise. The goal, he said, should be individualized patient plans.

"The literature suggests that for certain people, this could include an opioid therapeutic."

He reviewed some of the "abundant" evidence supporting the use of opioids for chronic pain. One of the more recent studies showed superior efficacy for the nortriptyline-morphine combination compared with either drug used as monotherapy.

He also pointed to an editorial published in JAMA earlier this year that noted there is an estimated 5 to 8 million people in the United States who successfully use opioids for long-term pain management.

A Double Standard?

Most professional societies recommend opioids as second- or third-line treatment. The International Association for the Study of Pain Neuropathic Special Interest Group recommends them as a first-line therapy under specific circumstances.

The 2009 American Pain Society/American Academy of Pain Medicine  clinical guidelines for the use of long-term opioid therapy in noncancer pain concentrates on patient selection, risk stratification, informed consent, opioid management plans, and monitoring, said Dr Argoff.

The Centers for Disease Control and Prevention (CDC) guideline also stresses the importance of assessing risks and addressing harms of opioids, as well urine drug testing. This guideline is designed for primary care practitioners, but it should help guide prescribing for all clinicians, he said. 

Although the CDC guideline supports the use of long-term opioid therapy for patients, Dr Argoff takes issue with some of the background in that guideline.

"They said there were no randomized, placebo-controlled studies of 52 weeks or greater, and therefore they couldn't say these agents were helpful long term. What patient would ever enroll in a study that involved potentially taking a placebo for 52 weeks?" he said.

He also pointed out that there are no studies of this length for other pain therapies, and none of the currently available chronic pain therapies have been approved based on this requirement.

"Do they think everyone is going to be helped if we stop using opioid therapy because everyone's scared? No, and it's not commensurate with the evidence or ethical care of a human being."

Individual patient differences must be factored into treatment approaches, said Dr Argoff. Practitioners must use their clinical judgment and experience, as well as their knowledge of available study results, in deciding how to treat and manage individual patients.

A Balanced Approach

While the evidence suggests opioids benefit some patients, Dr Argoff acknowledged the possible harm related to these drugs.

"I don't want to under-report the risks, all of them are very concerning," he said.

Risks related to opioid use can include sedation/confusion, nausea, constipation, respiratory suppression, death, sleep apnea, physical dependence, addiction, hypogonadism, and increased pain.

In addition, and notably, there's the risk for abuse. "Opioid analgesics are among the most commonly misused or abused pharmaceuticals," said Dr Argoff.

Overdose deaths from prescription painkillers increased to 16,651 in 2010 — about a fourfold increase since 1999.

But Dr Argoff is concerned by the common view that prescription opioid therapy is the major driving force behind drug overdoses.

"Please let's stop harping on it, because our patients may be able to benefit from this treatment."

He suggested avoidance of the term "opioid epidemic" because it suggests that the millions of Americans who benefit from long-term use of opioid therapy are an epidemic.

Patients need to be screened with a validated risk assessment tool before being prescribing opioids. "Don't do it after the horse is out of the barn," said Dr Argoff.

When treating patients with chronic pain, he advised healthcare professionals to "do a history and physical and get to know that person."

In addition, clinicians should order the "right diagnostic tests," review current and past treatments, and monitor patients on an ongoing basis.

The aim should be to "balance access to pain medicines with abuse prevention," said Dr Argoff.

Exit Strategy

Dr Argoff noted the importance of an "opioid exit strategy" in cases where there's no convincing benefit from the therapy despite dose adjustment, side-effect management, and opioid rotation; poor tolerance at analgesic doses; persistent adherence problems; or comorbid conditions.

Addiction is one of these comorbid conditions. Patients with behavior consistent with addiction should be referred for addiction management, said Dr Argoff.

But he stressed that "the disease of addiction is different than chronic pain, and we need to keep that in mind."

A possible exit strategy for patients with no addiction issues is to gradually taper the dose over and introduce nonopioid pain management strategies, such as psychosocial support, cognitive-behavioral therapy, physical therapy, and nonopioid analgesics.

Dr Argoff also reviewed the myriad nonopioid approaches to treating chronic pain, including nonsteroidal anti-inflammatory drugs, acetaminophen, antidepressants, anticonvulsants, oral local anesthetics, neuroleptics, muscle relaxants, topical analgesics, and nonmedical approaches.

He also noted emerging analgesics, such as botulinum toxin, cannabinoids, and bisphosphonates, and interventional therapies, such as epidural steroid injections and spinal cord stimulation, as potential therapies for chronic pain.

Dr Argoff reports he receives consulting fees from Pfizer, Nektar, Depomed, Salix, Daiichi Sankyo, Grunenthal, and Quest. He receives honoraria from Allergan, Depomed, AstraZeneca, Daiichi Sankyo, BDSI, Collegium, and Avanir. He is a stockholder of Pfizer and Depomed and receives royalties from Elsevier.

Academy of Integrative Pain Management (AIPM) 28th Annual Meeting. Presented October 21, 2017.

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