Opioids for Chronic Pain: Putting Evidence Into Perspective

Is the phrase, “opioid epidemic” appropriate, should its use be avoided? Kurt Kroenke, MD, comments.

Excessive concerns over opioid abuse and safety may cause reluctance among physicians to prescribe these agents for chronic pain, or prescribe even small amounts for severe acute pain, such as following surgical procedures, Kurt Kroenke, MD, noted in a recent opinion piece in JAMA.
Pair of reading glasses with the word "clarity" on the lensAmong the subset of individuals who do use opioids long-term, the majority of people do not misuse opioids or overdose.Dr. Kroenke believes that the phrase “opioid epidemic” should be avoided as only a small percentage of patients prescribed opioids progress to long-term use. In addition, among the subset of individuals who do use opioids long-term, the majority of people do not misuse opioids or overdose.

As a result of the concern over opioids “many patients on opioids for chronic pain were having their medicines discontinued even though they were taking the opioids appropriately without problems,” Dr. Kroenke told SpineUniverse. “This led to increased pain in some of these individuals and frustration.”

How Effective Are Opioids in Managing Chronic Pain?
“All analgesic categories have, on average, modest effects in reducing pain,” Dr. Kroenke told SpineUniverse. “Opioids provide equivalent pain relief to other analgesics, but there is considerable variability among individual patients and some patients respond better to one class of medications than another (just like some patients with high blood pressure respond better to one class of antihypertensive medication than another, though on average different blood pressure, medications are equally effective). Also, many patients with pain need combination treatment.”

Rational Use of Opioids for Chronic Pain
“Both nonopioid analgesics and non-pharmacological treatment strategies should be tried before starting opioids for chronic pain,” Dr. Kroenke said. “If opioids are used, the doses should be kept low for chronic pain (<50 mg morphine milligram equivalents per day), and opioids should be discontinued if not effective.”

“Opioids should be obtained from one provider and not multiple clinicians,” Dr. Kroenke continued. “The opioids should be stored in a secure place and not given to other persons. In general, one must be particularly cautious in using opioids in patients with a history of substance abuse as well as those on other controlled medicines like benzodiazepines.”

Dr. Kroenke also noted in his opinion piece that non-pharmacologic pain therapies are “promising alternatives” to pharmacotherapy, with cognitive behavioral therapy showing the strongest evidence of efficacy. Other beneficial treatments include pain self-management programs and regular exercise, with emerging evidence also suggesting possible benefit from yoga, mindfulness or meditation-based therapies, acupuncture, chiropractic care, and massage. However, therapies are “neither a panacea nor universal replacement for analgesics,” Dr. Kroenke wrote. Many patients with chronic pain would benefit from a combination of analgesic and non-pharmacological treatments.

Dr. Kroenke concluded in his paper that long-term effectiveness is weak for both pharmacologic and non-pharmacologic pain management options, and that “imperfect treatments do not justify therapeutic nihilism.” Rather, having a broad spectrum of agents with different mechanisms of action helps maximize the likelihood of achieving reduced pain levels in patients with chronic pain, Dr. Kroenke noted.

Updated on: 02/08/18
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