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Managing Chronic Pain: Opioids Are Often Not the Answer

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Opioids and researchThe term “silent epidemic” sometimes gets overused in medicine. But, for prescription opioid drugs, the term fits disturbingly well. In 2012, more than 259 million prescriptions were written in the United States for Vicodin, OxyContin, and other opioid painkillers. That equals one bottle of pain pills for every U.S. adult. And here’s an even more distressing statistic: in 2011, overdoses of prescription painkillers, most unintentional, claimed the lives about 17,000 Americans—46 people a day [1].

The issue isn’t whether opioid painkillers have a role in managing chronic pain, such as that caused by cancer or severe injuries. They do. What’s been lacking is an unbiased review of the scientific literature to examine evidence on the safety of long-term prescription opioid use and the impact of such use on patients’ pain, function, and quality of life. The NIH Office of Disease Prevention (ODP) recently convened an independent panel to conduct such a review, and what it found is eye-opening. People with chronic pain have often been lumped into a single category and treated with generalized approaches, even though very little scientific evidence exists to support this practice.

Based on its review of the literature and scientific research presented at the workshop, the seven-member panel concluded that chronic pain spans a multitude of conditions, presents in different ways, and requires an individualized, evidence-based approach to manage. The workshop was convened by ODP, the NIH Pain Consortium, the National Institute on Drug Abuse (NIDA), and the National Institute of Neurological Disorders and Stroke (NINDS).

Such individualization won’t be easy to achieve. Data were presented showing that people with peripheral pain, caused by tissue damage or inflammation, may respond better to opioids than other types of painkillers. This group includes people with cancer pain, rheumatoid arthritis, and severe pain due to injury. On the other hand, people with central pain syndromes, characterized by disturbances in the processing of pain by the brain and spinal cord, may respond better to antidepressants and anticonvulsants than to opioids. Such syndromes include fibromyalgia, irritable bowel syndrome, temporomandibular joint disorder, and tension headache. To add to the complexity, some workshop attendees cautioned against making sweeping statements about which types of patients are—and are not—most likely to benefit from prescription opioids.

The panel’s report, a summary of which was just published in the Annals of Internal Medicine [2], contains many other valuable insights. For example, I was deeply troubled by how little scientific evidence exists to support the safety and efficacy of long-term opioid use; most clinical studies on opioids and chronic pain have lasted 6 weeks or less. That is a serious knowledge gap, especially in light of the fact that up to 8 million Americans use opioids for long-term pain management—and the known side effects of short-term opioid use include nausea, mental clouding, and respiratory depression, along with overdose. Until more scientific evidence is generated on the effects of long-term opioid use, the panel suggests that people seeking help for chronic pain be initially encouraged to try non-drug approaches, such as physical or behavioral therapy. If such approaches fail to ease the pain, potentially riskier drug options, including non-opioid and opioid medications, could then be explored—but with great care.

As is increasingly the case for all areas of medicine, the panel concluded that the best pain management strategy is one tailored to identify and meet a patient’s individual needs. Taking this point a step further, the panel recommended that initial patient evaluations go beyond a standardized pain assessment (On a scale of 1 to 10, what is your pain level?) to consider more fully the whole patient—from quality of life and psychological wellbeing to the presence of other pain-causing conditions and sensitivity to pain.

A lot of this may be easier said than done. The expert panel acknowledged that, in the real world, many healthcare providers currently do not have the time or the tools to conduct such detailed evaluations, and some health insurers do not cover non-drug interventions or non-opioid drugs as first-line treatments for chronic pain. Furthermore, once a healthcare provider has prescribed an opioid drug to a patient with chronic pain, there are insufficient data on drug characteristics, dosing strategies, or tapering to guide clinical care effectively.

Clearly, NIH can’t address all of these challenges alone. However, we are taking very seriously the panel’s call for more research to generate the evidence-based, multidisciplinary approaches needed to bring safe and effective relief to the millions of Americans living with chronic pain.

The NIH is also doing everything it can to use the power of science to reduce the very serious public health problem of the abuse of opioid painkillers and other prescription drugs. In fact, on April 7, I’m scheduled to be among the NIH scientists presenting at The National Rx Drug Abuse Summit, which is a collaboration of professionals from government, business, academia, clinicians, treatment providers, counselors, educators, and advocates who are deeply concerned about prescription drug abuse.

References:

[1] Vital Signs: Opioid Painkiller Prescribing, Centers for Disease Control and Prevention, July 2014.

[2] National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Reuben DB, Alvanzo AAH, Ashikaga T, Bogat A, Callahan CM, Ruffing V, and Steffens DC. Annals of Internal Medicine. 2015 January 13.

Links:

Pathways to Prevention: The Role of Opiods in the Treatment of Chronic Pain (ODP/NIH)

NIH Pain Consortium

National Pain Strategy, Interagency Pain Research Coordinating Committee, U.S. Department of Health and Human Services

Prescription Drug Abuse (NIDA/NIH)

National Drug Facts Week (NIDA/NIH)

National Rx Drug Abuse Summit

NIH support: NIH Office of Disease Prevention; National Institute on Drug Abuse; National Institute of Neurological Disorders and Stroke

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