Opioids-A Rational Choice for Chronic Pain?

Author: Roger Chou

A number of factors came together to facilitate increased prescribing of opioids and prescribing to more people using higher doses. There was a perceived under treatment of chronic pain. Laws and regulations were passed in many states to permit the use of opioids for that purpose, for which they really had not been used before. There were data taken from palliative care settings that were extrapolated to chronic pain settings. We had a few case series that were done in chronic pain patients that appear to show limited risks, though people often forget these are in pretty selected patients and on relatively low doses. We also had the release of sustained release long-acting medications opioids that were perceived as being potentially safer even though that didn’t necessarily turn out to be the case. Unfortunately, the quality of the evidence for chronic opioid efficacy is limited and we have no randomized control trial versus placebo that’s longer than six months. The vast majority of the studies are 12 weeks or shorter. We have more evidence on harms associated with opioids, particularly serious harms like overdose, including dose-dependent risks. New data is pretty consistent in showing that higher doses are associated with increased risk. We’re also seeing some data on fracture risk, cardiovascular risks, and endocrinologic risks, that we didn’t have a whole lot of information on before.

The CDC guidelines really do give some guidance and standards for primary care clinicians. Among the important points in the guideline are that opioids aren’t the preferred therapy for chronic pain. We have a lot of non-opioid therapies that have some effectiveness and are a lot safer, that we need to think about pain as a biopsychosocial phenomenon. There is relatively clear guidance on dosing, how to approach higher doses, and ways to mitigate risks of higher doses. I think there’s a number of risk mitigation strategies, including avoiding use of benzodiazepines that maybe people didn’t fully appreciate until recently. On the downside, I think that some people may be using the guidelines somewhat rigidly. For example, with the patient who is above 90 milligrams, some physicians may be tapering all those people down. I don’t think that was necessarily the intent of the guideline. The guideline really talks about individualizing the treatment of the patient; assessing benefits and harms in each case. In some patients, there may be circumstances in which it’s appropriate to use higher doses but you need to be able to manage the increased risks associated with them and be able to really know and reassess that the patient is benefiting.

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