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 http://www.annals.org/content/155/5/325.abstract?etoc. Appreciate your thoughts and comments.