For Non Cancer Pain Opioids Can Still Help Some
The American Academy of Neurology and other groups have found no solid evidence that opioids are effective for chronic noncancer pain, yet many patients with such pain swear that opioids are the only treatment that helps them.
We contacted pain management experts and a variety of healthcare professionals to ask: Guideline Pros and Cons
James McGowan, MD: "On a whole, the use of chronic opiates over the last 20 years has done nothing to decrease rates of chronic pain in this country and very little to improve the lives of most patients who deal with chronic pain. At the same time, I do believe that some patients can experience long-term improvement in pain control and increased functioning with chronic opiates if these patients are carefully chosen and closely monitored. We swung the pendulum much too far in one direction with the use of opiates over the last 20 years, but I think we need to be very careful about swinging it too far in the opposite direction and completely abandoning the use of chronic opiates altogether. A balance must be struck in which judicious use of opiates in limited patient populations replaces widespread and unregulated usage."
Jack Freer, MD: "In general, the AAN position paper is a thoughtful and useful guide to the use of opioids in chronic noncancer pain (CNCP). In practice, however, it may be difficult for physicians to adhere to this kind of rigorous program. It is time consuming, since it requires an initial abuse risk assessment, individualized treatment contract, and ongoing monitoring with random urine testing. The regular re-evaluation of the treatment effectiveness needs to be function-oriented, and should, almost always, include other modalities (such as physical therapy). It also requires a physician to 'pull rank' and refuse requests to keep increasing the dose. A practitioner must be prepared to tell a patient (who says that the dose is inadequate), 'maybe this is not the right medicine for your pain.' Many physicians are not prepared to spend this time and energy and take one of two easier paths: either they become very loose in their prescribing of opioids, or they stop prescribing them altogether."
Lewis Nelson, MD: “These guidelines
Applications Across Specialties
Sabine Kost-Byerly, MD: "Patients may benefit from opioids to facilitate more effective physical therapy but if opioids make them too drowsy to participate, nothing has been gained. They may also benefit from opioids if recurrent reconstructive surgeries are needed after severe trauma. Pediatric and adolescent patients may receive opioids for weeks and sometimes months in these cases. It is important for providers to critically assess their patients during this time as it is all too easy for patients to seek the soothing effects of opioids to manage depressive symptoms that may have arisen due to their change in body image or prospects for an independent life. There is nothing wrong with acknowledging such feeling but opioids are the wrong drugs to treat them. "
Nelson: "In the emergency department I care for many patients being treated with chronic opioid therapy for a chronic pain syndrome. Most present for exacerbation of chronic pain, although complications related to the use of opioid therapy are a frequent reason as well. Management of chronic pain in the ED is complicated by the limited availability of a patient's medical record in the setting of nonobjective complaints (i.e., pain). Tolerance and hyperalgesia add to the complexity. However, the widespread use of prescription drug monitoring programs has allowed more judicious consideration of opioid use. In general, EDs do not prescribe the types of opioids most frequently used in this group of patients (those that are extended release or long acting)."
McGowan: "There are groups of patients whom I will sometimes treat with chronic opiates. In general, these are patients in whom I can clearly demonstrate an anatomic source of pain, such as severe arthritis, significant spinal degeneration, or a history of major trauma, as opposed to patients in whom the cause of pain is not easily identified. I will also consider opiates in patients with medical contraindications to other therapies, such as patients with severe arthritis who cannot take anti-inflammatories because of chronic kidney disease."
Prescribe with Caution
Kost-Byerly: "Although chronic pain in children is not as rare as we once thought, management of such pain with opioids actually remains rare, so rare that researchers have had a difficult time finding patients to evaluate the efficacy and safety of prolonged opioid therapy in younger patients. Most pharmacological therapy of chronic pain in children is based on studies performed in adults. Ideally, assessment and treatment of chronic pain in children and adolescents is interdisciplinary, including a number of healthcare providers such as the primary care physicians, physical therapists, behavioral psychologists, and for complex cases, pain specialists. Accordingly, limiting treatment to pharmacological interventions, including opioids, is often insufficient to help the patient."
McGowan: "I will usually avoid opiates in patients who seem fixated on opiates as 'the only thing that works' as opposed to those who are open to using other treatment modalities such as non-opiate medications, interventional pain techniques, and physical therapies. I also will generally avoid opiates in patients with history of misuse or abuse of prescription opiates, patients with other significant substance abuse problems, or patients with significant psychiatric issues. Although there is no 100% foolproof way to prevent bad outcomes with chronic opiates, I find that by sticking to these guidelines, chronic opiates can be used for the betterment of some patients.”
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