Literature Review

Opioids for Chronic Noncancer Pain—Risks Outweigh Benefits



The risks regarding chronic opioid therapy for chronic conditions such as headache, fibromyalgia, and low back pain likely outweigh the benefits, according to a position paper of the American Academy of Neurology (AAN) published in the September 30 issue of Neurology.

For more severe conditions such as destructive rheumatoid arthritis, sickle-cell disease, severe collagen disease, or severe neuropathic pain, “prescribers need specific guidance on dosing, publicly available brief tools to effectively screen patients for risk, and guidance on how to monitor patients for early signs of severe adverse events, misuse, or opioid use disorder,” according to author Gary M. Franklin, MD, Research Professor in the Departments of Occupational and Environmental Health Sciences, Neurology, and Health Services at the University of Washington in Seattle.

The position paper is a response to a request from the AAN’s Patient Safety Subcommittee for a review of the science and policy issues stemming from the growing public health epidemic of prescription opioid-related morbidity and mortality in the United States. More than 100,000 people have died from prescribed opioids in the US since a policy change went into effect in the late 1990s. Among persons ages 35 to 54, the highest-risk group, the number of deaths related to opioids is greater than that resulting from firearms and motor vehicle accidents.

Dr. Franklin noted that primary care physicians are the leading prescribers and are “more likely to use opioids with confidence in environments that support use of best practice tools to assist with these often complex and difficult patients.” To use opioids safely and effectively for chronic noncancer pain, prescribers can do the following things, according to Dr. Franklin:

• Draft opioid treatment agreements

• Screen for prior or current substance abuse or misuse (eg, alcohol, illicit drugs, or heavy tobacco use)

• Screen for depression

• Use random urine drug screening prudently (eg, to identify diversion or nonprescribed drugs)

• Avoid prescribing concomitant sedative-hypnotics or benzodiazepines

• Track pain and function to recognize tolerance and monitor effectiveness

• Track the daily morphine-equivalent dose using an online dosing calculator

• Seek help if the morphine-equivalent dose reaches 80 to 120 mg and pain and function have not substantially improved

• Use the state Prescription Drug Monitoring Program to monitor all sources of controlled substances.

“Current opioid prescribing practices have been associated with … morbidity and mortality of epidemic proportions,” stated Dr. Franklin. “The determination of functional benefit of any pain management intervention or treatment is important in the management of patients with chronic pain conditions.

Patients on chronic opioid therapy should be managed according to best practices and universal precautions as outlined,” he continued. “If daily dosing exceeds 80-120 mg/day morphine-equivalent dose, consultation with a pain management specialist is recommended, particularly if pain and function have not substantially improved. Opioid therapy should be only part of a multifaceted approach to pain management…. Ongoing research and data collection regarding opioid efficacy and management are needed, as well as revision of state and federal laws and policy to ensure patient safety.”

Colby Stong

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