COMMENTARY

When Are Opioids the Right Treatment?

Charles E. Argoff, MD

Disclosures

December 15, 2017

I am Charles Argoff, professor of neurology at Albany Medical College, and director of the Comprehensive Pain Center at Albany Medical Center in Albany, New York.

I believe that most, if not all, of you who are viewing or reading this would agree that the management of chronic pain, whether non-cancer- or cancer-related pain, is often complex. Certainly, it is not easy. Among the complexities include making a proper diagnosis or diagnoses, and recognizing a variety of medical comorbidities. We typically think of these comorbidities as such things as cardiovascular disease, diabetes, and other medical conditions. But included among the comorbidities are substance abuse, depression, anxiety disorder, attention-deficit disorder, and other mental health disorders, in addition to other medical conditions.

Identifying and successfully implementing an appropriate and effective treatment regimen poses particular challenges to clinicians. I know that it isn't always easy to figure out what is best for an individual person. Further complicating this problem is the recognition that certain pharmacologic therapies for chronic pain—specifically chronic opioid therapy—may be associated with explicit harms, including unintentional overdose and death, even when the prescribed medication is used properly. Moreover, opioids may be associated with illicit nonmedical use, death, and other harms.

With this in mind, however, it is also important to acknowledge that the Centers for Disease Control and Prevention (CDC) guideline[1] for using chronic opioid therapy for patients with chronic non-cancer pain notes that, for certain individuals, chronic opioid therapy may be an appropriate treatment. In fact, in a Medscape interview[2] in May 2017, one of the authors of this guideline acknowledged a role for chronic opioid therapy for chronic pain, noting that individualized decision-making needs to occur when considering such treatment.

A recent JAMA editorial[3] estimated that between five and eight million people in the United States in fact benefit from chronic opioid therapy for chronic non-cancer pain. That is not a small number.

Included in the CDC guideline is a concern and warning to, if at all possible, avoid the co-prescribing of both chronic opioids and benzodiazepines. But the guideline also recognizes that for certain people this combination may be medically appropriate.

A 2016 US Food and Drug Administration (FDA) communication[4] regarding the medical treatment of opioid addiction—that is, people who are being treated with opioid therapy (buprenorphine or methadone) for opioid addiction—states, "The FDA is advising that the opioid addiction medications, buprenorphine and methadone, should not be withheld from patients taking benzodiazepines or other drugs that depress the central nervous system."

Thus, in multiple guidelines and in multiple communications, we have a sense that chronic opioid therapy can be effective. It needs to be used quite carefully and safely but can be effective for a number of people with a variety of medical conditions—not only for chronic pain but for the treatment of opioid misuse and opioid addiction itself.

Considering these complexities, I want to pose several questions and a challenge: How many of you have successfully managed people with chronic pain by using chronic opioid therapy? We know that published randomized controlled studies typically show that a certain percentage of those involved in the study do well with opioids while others do not receive as much benefit. What is happening in your practice? Are you seeing that a certain subset of your patients do well on chronic opioid therapy? Do none of them do well? Do many of them do well? In your experience, what factors predict which patients benefit from opioid therapy?

Please share your patient vignettes with us by commenting at the end of this blog and sending us de-identified case presentations showing how you may have successfully treated individuals with chronic opioid therapy. This is quite important and certainly would help us, as a community of medical providers in the United States, to understand how to better use this particular class of therapy for people who experience chronic pain.

Thank you so much for your attention. I am Dr Charles Argoff. I hope you have a great day.

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