New Study Confirms Existing Guidelines for Prescribing Opiates in the Treatment of Chronic Pain
By Neal Roberts, PharmD
Just this past week a new study from the Department of Veterans Affairs (VA) System published in the Journal of the American Medical Association (JAMA) provides further evidence that the decades old conventional practice of prescribing opioids for certain types of chronic pain may be no more effective than over-the-counter remedies found at the drugstore.
The SPACE randomized clinical trial enrolled 240 patients with moderate to severe chronic back pain or hip or knee osteoarthritis pain. Participants were randomly assigned to receive either opioid or non-opioid drug therapy. The study found that treatment with opioids including morphine and oxycodone in various formulations were not superior for improving pain-related function to treatment with non-opioid products such as acetaminophen or ibuprofen over a 12-month period.
Opioids such as hydrocodone, oxycodone, morphine and potent derivatives such as fentanyl are commonly prescribed for pain. An estimated 20% of patients presenting to physician offices with non-cancer pain symptoms or pain-related diagnoses (including acute and chronic pain) receive an opioid prescription. In 2016, health care providers wrote 259 million prescriptions for opioid pain medication, enough for every adult in the United States to have a bottle of pills.
It should be noted that opiates are very effective and recognized as appropriate in the treatment of acute pain associated with surgical procedures and trauma. Opiates also have an established role in the management of cancer related pain and palliative care at end of life. However, many experts believe that the use of opioids to treat many common types of chronic pain is ineffective and has contributed significantly to our current epidemic of abuse.
Chronic pain has been variably defined as pain that typically lasts >3 months or past the time of normal tissue healing. Estimates of the prevalence of chronic pain vary, but it is clear that the number of persons experiencing chronic pain in the United States is substantial. Based on a survey conducted during 2001–2003, the overall prevalence of common, predominantly musculoskeletal pain conditions (e.g., arthritis, rheumatism, chronic back or neck problems, and frequent severe headaches) was estimated at 43% among adults in the United States.
Opioid pain medication use presents serious risks, including overdose and opioid use disorder. From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased markedly. Sales of opioid pain medication have increased in parallel with opioid-related overdose deaths and seemed to coincide with marketing of new sustained release long-acting formulations such as OxyContin in the 1990’s.
Prevention, assessment, and treatment of chronic pain are challenges for health providers and systems. Pain might go unrecognized, and patients, particularly members of racial and ethnic minority groups, women, the elderly, persons with cognitive impairment, and those with cancer and at the end of life, can be at risk for inadequate pain treatment. Patients can experience persistent pain that is not well controlled. There are clinical, psychological, and social consequences associated with chronic pain including limitations in complex activities, lost work productivity, reduced quality of life, and stigma, emphasizing the importance of appropriate and compassionate patient care.
Primary care clinicians report having concerns about opioid pain medication misuse, find managing patients with chronic pain stressful, express concern about patient addiction, and report insufficient training in prescribing opioids. Across specialties, physicians believe that opioid pain medication can be effective in controlling pain, that addiction is a common consequence of prolonged use, and that long-term opioid therapy often is overprescribed for patients with chronic non-cancer pain. These attitudes and beliefs, combined with increasing trends in opioid-related overdose, underscore the need for better clinician guidance on opioid prescribing.
To satisfy the need for better evidence based advice for primary care clinicians, the Centers for Disease Control (CDC), the American Pain Society, the US Department of Veterans Affairs and other state medical societies have all released recent (2016-17) treatment guidelines for chronic pain. Taken as a whole, these guidelines from independent organizations are remarkably similar in their suggested approach by recommending against initiation of long-term opioid therapy for chronic pain.
These updated guidelines favor use of non-pharmacologic strategies such as physical therapy and prescribing of non-controlled substances such as acetaminophen and non-steroidal anti-inflammatory agents like ibuprofen as first-line therapy. If opiates are prescribed, the CDC and other organizations recommend a short duration of therapy, lower maximum recommended daily dosages, prohibitions on combining opiates with benzodiazepines, evaluation for mental health and substance abuse disorders, and strict risk-mitigation policies such as random drug-testing, pill counts, and online prescription database queries to identify signs of abuse or diversion.
Although the guidelines for initiating therapy for chronic pain are fairly straightforward, many primary care providers are left in a quandary about what to do for patients that have been taking opiates for years. Understandably, most patients accustomed to filling monthly opioid prescriptions are hesitant to reduce or replace them with alternative therapies despite well-intended efforts to educate patients and caregivers on the risks vs. benefits.
Many physicians feeling pressure from demanding patients, medical boards, drug-enforcement agencies, and insurance companies have decided to curtail or refuse to prescribe opiates altogether. Regardless of the reason, when opioids are reduced or discontinued, a taper slow enough to minimize symptoms and signs of opioid withdrawal should be used. Patients with physical dependence upon opiates who are not weaned appropriately place additional burdens upon emergency rooms and other providers who are often sought out for relief from acute withdrawal symptoms. These patients may try to obtain prescription and non-prescription opiates such as heroin from illegal sources.
To avoid these downstream consequences, primary care clinicians should collaborate with mental health providers and with other specialists as needed to optimize non-opioid pain management and provide psychosocial support for anxiety related to the taper. Nurse care managers and behavioral health social workers, if available, should be engaged to help patients effectively cope with the psycho-social aspects of chronic pain and to assist in locating treatment providers for opioid use disorder.
Despite recent evidence like the SPACE trial and evidence based guidelines from well-respected organizations like the CDC, wide-variations in opioid prescribing practices are still evident from state and national statistics. The translation of research into clinical practice often takes many years and misconceptions about the value of certain therapies will linger even longer in the public domain. Emtiro Health strives to support primary care providers and local communities dealing with opioid abuse. We have a team of care managers, pharmacists, and behavioral health experts dedicated to driving change in the provider community while ensuring that patients receive effective and compassionate care.