Posted by & filed under Noah's Notes.

Over the last 25 years our approach to chronic pain has shifted dramatically. Beginning around 1990 and without science to support the approach, it was determined that chronic pain should be treated with opioid pain killers (commonly referred to as narcotics – medications like oxycodone, Oxycontin, morphine and Vicodin), that there was no unsafe dose and that the risk of addiction was very low.

These unsupported ideas arose largely from the companies making these drugs (and making a profit from them) and were promoted by some well-meaning experts who also happened to have a financial relationship with these companies and some corrupt experts. The result has been a 600% increase in opioid prescribing in the US since 1990, a 265% increase in prescription overdose deaths in men, a 400% increase in prescription overdose deaths in women, equally dramatic increases in treatment for “near miss” overdoses and for addiction to prescription opioids and no actual improvement in the function of people suffering from chronic pain. In fact we now know that the risk of addiction for people taking daily opioids for chronic pain is about 35% (not the less that 1% which was touted by the “experts” hired by the drug makers). And most importantly, on September 30 this year the Agency for Healthcare Research and Quality released a new document on Evidence Based Practice entitled “The Effectiveness and Risks of Long-Term Opioid Treatment of Chronic Pain”. Given the myriad problems associated with long term opioid use and Maine’s ongoing dubious distinction as a leader in high dose opioid prescribing this publication is timely in its release and its conclusions are powerful. It is a comprehensive review of the literature related to long-term opioid use for chronic pain performed by a panel of experts which include specialists in pain, epidemiology, occupational health, pharmacology, anesthesia, chronic disease, and pediatric pain.

Although the findings of this group are not new, the expertise of the authors and reviewers and the comprehensive nature of the review should lead to dramatic changes in our approaches to treating chronic pain. Two brief sections of this 200 plus page report are most telling. First, in a section entitled “Key Findings and Strength of Evidence” they state:

For effectiveness and comparative effectiveness, we identified no studies of long term opioid therapy in patients with chronic pain versus no opioid therapy or non-opioid therapies that evaluated outcomes at 1 year or longer. No studies examined how effectiveness varies based on various factors, including type of pain and patient characteristics…and no cohort studies on the effects of long-term opioid therapy versus no opioid therapy on outcomes related to pain, function or quality of life were found.

In other words there is no evidence of benefit from long-term opioids in the treatment of chronic pain. On the other hand the report lists the evidence related to abuse, addiction, and accidental overdose, and also listed evidence of increased risk of bone fractures and myocardial infarction (heart attack).

Finally, in their conclusions the authors state that, “Evidence on long-term opioid therapy for chronic pain is very limited, but suggests an increased risk of serious harms that appears to be dose dependent”. That is, the higher the dose the greater the risk of harm.

Health care providers and their teams must work to reduce opioid dosing for chronic pain. It is a challenging undertaking which requires energy, commitment, a unique skill set for which few of us have been trained, and it will require unwavering support from our colleague, co-workers and communities. As we move forward we will also need to improve our evaluation for, documentation of and treatment for diagnoses of addiction in a portion of this population of patients. It is not the easy thing to do, but it is the right thing to do for our patients, their families and our communities.

Noah Nesin, MD

Dr. Nesin, Vice President of Medical Affairs for PCHC, is a family doctor with 30 years of experience.

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