Opioids for Pain Management: Less is More

oxycodoneApproximately 100 million Americans suffer from chronic pain. Nationwide, chronic pain causes more disability than cancer and heart disease combined, and costs $550 million annually in lost workdays.

Clinicians classify pain as acute or chronic. Acute pain is "useful" in that it immediately signals the nervous system that something is wrong and requires attention. Its cause is usually easy to identify and straightforward to treat. Acute pain is time-limited, usually lasts a month or less, and is responsive to opioid medication and other therapies.

On the other hand, chronic pain is a complex disorder of the whole person that persists for three to six or more months and serves no useful purpose. It is often associated with a long-term, incurable or intractable medical condition or disease. Though its cause can be difficult to identify, chronic pain frequently results from damage to nerve-related tissue or altered processing of pain in the central nervous system.

Chronic pain is notoriously difficult to treat effectively because in addition to the physical experience of pain, chronic pain can cause tremendous emotional suffering―the psychological reaction to ongoing pain. Anxiety, fear, and anger often accompany chronic pain and intensify an individual's overall experience and perception of pain.

Opioid drugs such as oxycodone (OxyContin, Percocet, Percodan) and hydrocodone (Lortab, Norco, Vicodin) are by far the most prevalent treatment for chronic pain today. These medications have extremely effective analgesic (pain-relieving) properties and were once used primarily to treat cancer pain or acute pain, such as from injury or surgery. In 1995, however, pain advocacy groups, often with funding from drug companies, began to issue policy statements endorsing the use of opioids to treat chronic pain, while downplaying the risks of overdose and addiction. At the same time, pharmaceutical companies spent vast sums of money marketing these drugs to healthcare providers and directly to consumers. These efforts to expand the market for opioid painkillers created billions in profits for drug companies but have not resulted in improvements in treatment outcomes or quality of life for most patients.

In 1999, the Veteran's Administration launched an initiative that encouraged healthcare providers to document pain in all patient evaluations using a 0-to-10 rating scale, and treat the reported pain with medication. The Joint Commission (formerly JCAHO), a national accrediting entity for hospitals and treatment centers, soon endorsed this method and declared pain "The Fifth Vital Sign." This mandated that the assessment and "proper" treatment of pain become routine for all patients, just like measurements of temperature, pulse, respiratory rate, and blood pressure.

An Opioid Epidemic

Between 1991 and 2010, prescriptions for opioid analgesics increased from 75 million to 209 million. The rationale has been that we don't want people to suffer; we don't want to deprive people of pain treatment. But this approach has backfired catastrophically.

  • According to the CDC, in 2010, enough opioids were prescribed to treat every person in the US with Vicodin 5mg every four hours for a month.
  • The U.S contains only 4 percent of the world's population yet consumes 80 percent of the world's opioids.
  • In 2009, more people in the US died from unintentional drug overdoses than from motor vehicle accidents. The rise in overdose deaths has been linked to the increased availability and misuse of prescription opioid pain medications.
  • There are now more deaths from prescription opioid overdoses than from cocaine and heroin combined.

Challenges

To assess chronic pain, clinicians typically rely on patient self-reports. However, patients with chronic pain often can't tell the difference between emotional pain and physical pain. So relying only on what they say about the severity of their pain may not be a valid or safe way to determine the appropriate use and dose of medication, particularly if the patient also has addiction.

The US Food and Drug Administration (FDA) recently convened a two-day public meeting on the efficacy of opioids as a treatment for chronic pain not related to cancer. More study is needed, but pain doctors and researchers agreed that there is a lack of scientific evidence to support the notion that opioids are effective as a long-term treatment for chronic pain. Statements in product labeling that say opioids are indicated for the treatment of chronic pain may eventually have be removed.

Meanwhile, just last week, the FDA approved a sustained release pharmaceutical of pure hydrocodone (Zohydro ER), which is offered as a treatment for chronic pain unresponsive to other measures. This will be the first pure hydrocodone product released in the United States, and its approval proceeded despite a vote against it by an expert panel in December 2012. In combination with acetaminophen or other medications, hydrocodone was already the most prescribed medication in the country in 2011. However, the FDA took another action last week that may at least partially offset this potential increase in hydrocodone availability. The FDA is changing the classification of hydrocodone from Schedule III to Schedule II, which will mean all prescriptions for hydrocodone must be in writing (not phoned in) and can no longer include refills.

While opioid medications can be quite effective in diminishing pain in the short-term, there are serious side effects and other risks associated with the long-term use of opioids. Risks of opioids include cognitive impairment, hormone and immune system abnormalities, sleep disturbance, constipation, and hyperalgesia (increased pain), as well as tolerance, physical dependence, and addiction.

Conclusions

Opioids and opioid-combination drugs are overprescribed. We do not yet have studies that discern the true outcome of long-term opioid treatment for chronic pain and the incidence of potential problems. Patients understandably wish to be pain-free and doctors want to help them. But it may not be realistic to expect a medication or mix of medications to completely relieve chronic pain and the suffering that accompanies it. Further, because long-term use of opioids may increase pain, medications provided by well-intentioned prescribers may actually make their patients' suffering worse. Therefore, the problems from the long-term use of opioids for pain frequently outweigh the benefits.

Opioid medications should be prescribed only when alternative treatments, including physical and psychosocial interventions as well as non-opioid medications, have been exhausted. Many alternative treatments are available that may be effective for chronic pain sufferers. These include exercise, stretching, massage, mindfulness meditation, acupuncture, physical therapy, and cognitive-behavioral therapy to name only a few. Good nutrition and smoking cessation improve painful conditions across the board.

When opioids are prescribed, close monitoring is essential. If pain does not respond to a dose increase, it may be time to discontinue opioids. In any event, prescribers and their patients on opioids are wise to have an "exit strategy," a plan for how they will safely withdrawal and discontinue opioids should they decide any benefits from these powerful but potentially harmful medications are no longer worth the risks.

The NCADD Addiction Medicine Update provides NCADD Affiliates and the public with authoritative information and commentary on specific medical and scientific topics pertaining to addiction and recovery.

 

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Sunday, 17 June 2018
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