“Long-Term Opioid Therapy Reconsidered:” a look at an Annals paper

This just out from Annals of Internal Medicine today. Overall a good “idea and opinion” paper.  Well worth reading. I wish the authors had defined that this applied for non palliative care pain management; even in palliative care we can get into long term opioid therapy. But much of what is written applies to all prescribing of opioids, acute and chronic.  I do agree with the statement of the authors.

Debate about long-term opioid therapy seems to pit commitment to compassionate care of patients with chronic pain against adequate response to an epidemic of prescription opioid abuse and overdose. These goals need not be mutually exclusive.

Clinicians and their professional societies can take action now to increase the margin of safety for patients and society while preserving access to long-term opioid therapy for carefully selected and closely monitored patients. We propose steps to achieve these objectives.

So who are the carefully selected and closely monitored patients?

  • A middle aged male school teacher  who takes 4-5 Norcos (hydrocodone/acetaminophen) per day from inoperable spinal arthritis who cannot tolerate NSAIDs (Non smoker, occasional No constipation. No drowsiness and continuing to work)?
  • A middle aged man who has a severe peripheral neuropathy from the chemotherapy used to treat his colon cancer? He is maintained on Morphine ER 180 mg two /times day and has had no relief with all the other adjuvants and has few side effects from morphine other than constipation for which he has a strict bowel regimen which maintains a good colostomy output.
  • A middle aged man on disability with severe HIV related peripheral nerve pain who is maintained on Morphine ER 30 mg three times/day?  He drinks a few beers most days and has used marijuana in the past but not currently.  Pain is reduced from an 8/10 to a 3/10 with morphine.  After 6 years of stable therapy with no dose escalation and no early fills ever, how often should I see this man; monthly, bimonthly, three monthly, every 6 months.

As with all papers, one can always find small points with which to take issue.  While the abstract says the higher-dose regimens account for the majority of opioids dispensed, I could not find the supporting data in the paper itself.  The paper lists many studies regarding the side effects and risks that themselves do not reach the same high level of evidence that are lacking for the use of opioids in chronic non cancer pain.   Interestingly the paper does not mention the impact of laws and regulations on increasing opioid diversion and seems to place the focus primarily on the lack of education of physicians.

And the education tips provided are pretty good. I have few problems with the “cautious prescribing practices.”  I occasionally recommend extended-release opioids for patients after major cancer surgery for whom I know acute pain is going to take considerable time to resolve (e.g.’s Whipple’s procudure: having your pancreas, part of your liver, part of your bowel removed for pancreatic cancer).

The authors call for more research and evidence. Totally agree. The paper also suggests that “limiting long-term opioid therapy to patients for whom it provides decisive benefits could also reduce risk.”  Does this mean that short-term therapeutic trials with opioids are an important part of chronic pain management?

Paper is at  Appreciate your thoughts and comments.

About Pain policy & palliative care

Improving global pain relief by achieving balanced access to opioids worldwide


4 thoughts on ““Long-Term Opioid Therapy Reconsidered:” a look at an Annals paper

  1. Jim,

    Thanks for covering this paper even though it’s critical of treating chronic pain with opioids.

    With regard to your suggested patient scenarios, all of these folks should be selected carefully and monitored closely. I don’t know if these cases are based on real people that you’re treating… but I’m somewhat skeptical that the middle aged guy on 360mg of morphine/day is doing as well as you think and that constipation is his only SE. Assuming he’s actually taking all the pills and not diverting some or all of them… his testosterone level is probably very low. He’s also at increased risk for overdose death and other serious adverse events. I wonder how his dose got so high?


    Posted by Andrew Kolodny | September 6, 2011, 6:37 PM
  2. It is refreshing to see information about patient education making headlines! I am working with a consumer health company who is currently doing research on this topic. We have created a survey where consumers can voice their opinions on where and when they want to recieve information regarding side effects. So voice your opinion and let us know what you think! Please complete this survey and feel free to post it on your facebook and share with your friends!

    (web site link deleted as link to online pharmacies promoting opioids. If you wish to follow up with this please contact @drugpatient directly: jfc)
    (@drugpatient: please respect the integrity of this site and not post links that promote online sales of opioids).

    Posted by Patient Drug (@DrugPatient) | September 8, 2011, 2:19 PM
  3. I don’t understand why addiction is a concern for people that have to be on a medication for the rest of their life. When people need to be on a medication long term to increase their quality of life and make it possible for them to get out of bed and go on with their day. I get so tired of druggies and junkies ruining stuff for everyone else. As a chronic pain sufferer; I know what its like to be put off by doctors because they have to suspect everyone of being an addict. I would go in asking for preventative medication and they’d treat me like an addict even though I had refused narcotics for years.

    Posted by dormantcharge | September 13, 2011, 5:50 PM
  4. Yes, it seems very interesting. Opioids are very good for people who suffer in general, but since some people use them to have fun, people who suffer should pay. I do not agree with it. Thank’s

    Posted by Robert | October 31, 2012, 6:07 AM

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