'Nopioids' for Chronic Pain: Only When Nothing Else Works

Neha Pathak, MD; Daniel Clauw, MD


September 20, 2023

This transcript has been edited for clarity.

Neha Pathak, MD: Hello. Today we're talking to Dr Daniel Clauw, a professor at the University of Michigan in Ann Arbor, who is running a major trial on treatments for chronic back pain. When I started practicing, it was really opioid-centric in terms of our treatment modalities. Now, the pendulum is swinging to what some people are calling nopioids, where people — primary care providers, specifically — don't necessarily even want to prescribe opioids.

How do you see opioids fitting into the multimodal pain approach, the way that we're thinking about managing patients with chronic pain?

Daniel Clauw, MD: Let me first acknowledge that as a pain researcher, I'm on one far end of the continuum with respect to opioids, and I think opioids should hardly ever be used to treat chronic pain. I really worry — and I give lectures about this — that those of us in the pain field haven't been as strongly anti-opioid as we should be.

If you look, there have only been a couple of studies that have randomized someone with chronic pain to opioids vs non-opioids and followed them for a year, including the Krebs study 4 or 5 years ago, and then a very recent study did the same thing.

What people failed to note in both of those studies is that the group of people that received the opioids didn't just not do better than the non-opioid people, they did worse. In both of those trials, when people got to a year out, the opioid-treated patients had statistically worse pain scores than the non–opioid-treated patients; these were two long, prospective trials where people were randomized to either opioid or non-opioid therapy.

I have always worried that in any group of chronic pain patients, if you look at those on opioids, they always look worse in every way. People say that's been confounded by indication and that we put the people with worse pain on opioids. I don't think that's true. I think that opioids actually make pain worse for a subset of patients with chronic pain. Because of that, we really should be using these as a last line if people are refractory to everything else. There just is not the evidence base.

The other thing that I don't think people are aware of is how high the all-cause mortality is. When someone is on an opioid, it's 70% higher or double in every year. It's not because of overdose deaths, but it's due to higher rates of myocardial infarctions, motor traffic accidents, suicides, and many other things that people die of at very high rates when they're taking an opioid.

I'm sorry about the rant, but I really do think we should be putting opioids where they were 25 years ago: You use them only when nothing else has worked.

Pathak: I think that's really helpful, and I appreciate the synthesis of the information. I think that, for many of us, it's very confusing and there's a regulatory hurdle. There's also the patient expectation when they come in to the office and then there becomes this adversarial relationship sometimes because of what we have to do with regard to pain contracts or pain agreements, where you shift from feeling like you're a doctor to becoming a detective. It leads to difficulty in that physician-patient relationship.

Thank you to Dr Clauw for joining us and being our pain consultant, really helping us think about managing chronic pain in the post-opioid world.

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