Considerations in 2017–2018 for the Use of Opioids in Non-terminal Pain
- 36 Downloads
Purpose of Review
Despite external pressure on medical providers to reduce opioid prescribing, patients with chronic, non-terminal pain continue to present to their physicians requesting pharmacologic assistance with low back pain, arthritis, neuropathy, migraine headaches, and other forms of non-terminal pain lasting more than 3 months.
In the last 2 years, updated systematic meta-analyses and one randomized, controlled trial have still been unable to find evidence of benefit from use of opioid therapy longer than 3 months for treatment of non-terminal pain.
With substantial evidence about the potential risks of opioid use and a relative paucity of evidence supporting their long-term use, prescribers are asked to be more judicious in their selection of patients, continuously weighing the risks and benefits.
KeywordsOpioid Chronic pain Chronic non-cancer pain Chronic non-terminal pain
Compliance with Ethical Standards
Conflict of Interest
Kenneth S. Tseng declares that he has no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 1.Associated Press. Number of prescriptions for opioid painkillers drops dramatically in U.S. [Internet]. NBC News. 2018 April 20. [cited 2018 October 8]. Available from: https://www.nbcnews.com/health/health-news/number-prescriptions-opioid-painkillers-dropsdramatically-u-s-n867791
- 2.• Qaseem A, Wilt TJ, McLean RM, Forciea MA. Noninvasive treatments for acute, subacute, and chronic low back pain: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2017;166(7):514–30 Consensus guideline from ACP for treatment of low back pain by primary care physicians.CrossRefGoogle Scholar
- 3.American Society of Anesthesiologists Joint Committee on Pain Medicine and Ad Hoc Committee on Prescription Opioid Abuse. Considerations for long-term opioid use in chronic, non-cancer pain conditions. [cited; Available from: https://www.asahq.org/resources/resources-from-asa-committees/considerations-for-long-term-opioid-use.
- 5.•• Faculty of Pain Medicine. Opiods Aware: a resource for patients and healthcare professionals to support prescribing of opioid medicines for pain. 2015 [cited; Available from: http://www.fpm.ac.uk/faculty-of-pain-medicine/opioids-aware. Web-based guidelines from Faculty of Pain Medicine, Royal College of Anaesthetists, with support from the British Pain Society and Public Health England.
- 6.•• Faculty of Pain Medicine, Austalian and New Zealand College of Anaesthetists (FPMANZCA). Recommendations regarding the use of opioid analgesics in patients with chronic non-cancer pain. 2015 [cited; Available from: http://fpm.anzca.edu.au/documents/pm1-2010.pdf. Consensus Australian guidelines.
- 7.•• Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016. MMWR Recomm Rep. 65(1):1–49 Systematic review of studies performed up until April 2015. They found insufficient evidence to answer the question of the efficacy of long-term opioid therapy versus non-opioid alternatives. Google Scholar
- 8.Virginia Board of Medicine. Regulations governing prescribing of opioids and buprenorphine [Internet]. Henrico, Virginia: Commonwealth of Virginia, 2018. Regulation number 18 VAC 85-21-10. [cited 2018 October 8]. Available from: https://www.dhp.virginia.gov/medicine/
- 9.Brennan T. The balancing act: helping ensure appropriate access to opioids while minimizing risk. 2017 February 28 [cited; Available from: https://payorsolutions.cvshealth.com/insights/balancing-act.
- 14.Stannard C, Gaskell H, Derry S, Aldington D, Cole P, Cooper TE, et al. Hydromorphone for neuropathic pain in adults. Cochrane Database Syst Rev. 2016;24(5):CD011604.Google Scholar
- 15.• Mcnicol ED, Ferguson MC, Schumann R. Methadone for neuropathic pain in adults. Cochrane Database Syst Rev. 2017;5:CD012499 Cochrane library systematic review of three small RCTs. Two studies were combined to show 11/29 subjects reported 30% improvement in symptoms versus 7/29 subjects on placebo. One study reported statistically significant improvement in pain intensity with methadone 20 mg/day but not 10 mg/day. These studies provided very low-quality evidence due to risk of bias, short study duration, crossover study design, and heterogeneity of findings. PubMedGoogle Scholar
- 17.• Gaskell H, Moore RA, Derry S, Stannard C. Oxycodone for pain in fibromyalgia in adults. Cochrane Database Syst Rev. 2016;9:CD012329 Cochrane library systematic review of oxycodone for treatment of fibromyalgia, which was previously included in systematic reviews of neuropathic pain. PubMedGoogle Scholar
- 19.• Santos J, Alarcao J, Fareleira F, Vaz-Carneiro A, Costa J. Tapentadol for chronic musculoskeletal pain in adults. Cochrane Database Syst Rev. 2015;27(5):CD009923 Cochrane library systematic review of four RCTs comparing tapentadol ER, oxycodone CR, and placebo for chronic musculoskeletal pain. Three with 12-week follow-up, one open-label study lasting 52 weeks. All four studies were funded by the drug manufacturer. Compared with placebo, tapentadol ER was associated with a mean reduction of 0.56 on 11-point NRS. Three out of 10 patients on tapentadol reported greater than 50% improvement, compared with 2 out of 10 on oxycodone or placebo. Study limitations were significant: including high heterogeneity in some outcomes, high rates of withdrawal from the studies, and lack of data for some primary outcomes. Google Scholar
- 25.Gomes T, Greaves S, van den Brink W, Antoniou T, Mamdani MM, Paterson JM, et al. Pregabalin and the risk for opioid-related death: a nested case-control study. Ann Intern Med. 2018 Aug 21.Google Scholar
- 26.Chou R, Deyo R, Devine B, Hansen R, Sullivan S, Jarvik JG, et al. The effectiveness and risks of long-term opioid treatment of chronic pain. Evidence Report/Technology Assessment No. 218. (Prepared by the Pacific Northwest Evidence-based Practice Center under Contract No. 290-2012-00014-I.) AHRQ Publication No. 14-E005-EF. Rockville, MD: Agency for Healthcare Research and Quality, 2014.Google Scholar
- 27.•• Krebs EE, Gravely A, Nugent S, Jensen AC, DeRonne B, Goldsmith ES, et al. Effect of opioid vs nonopioid medications on pain-related function in patients with chronic back pain or hip or knee osteoarthritis pain: The SPACE randomized clinical trial. JAMA. 2018;319(9):872–82 RCT of US Veterans Administration primary care clinic patients with chronic back pain or hip or knee osteoarthritis. Patients were randomized to either opioid (morphine sulfate, oxycodone, or hydrocodone/acetaminophen) or non-opioid (acetaminophen or NSAID) and followed for 12 months. Primary outcome was pain-related function (Brief Pain Inventory [BPI] interference score) and the secondary outcome was pain intensity (BPI severity). There was no significant difference between the groups in pain-related function, and patients in the non-opioid group reported significantly better pain severity score at 12 months. CrossRefGoogle Scholar
- 29.• American Pain Society. Guideline for the use of chronic opioid therapy in chronic noncancer pain: evidence review. Chicago: American Pain Society, American Academy of Pain Medicine Opioids Guidelines Panel; 2009. The APS published the first systematic review of opioid therapy for chronic non-terminal pain that laid the ground work for the CDC recommendations. Google Scholar
- 37.• Els C, Jackson TD, Kunyk D, Lappi VG, Sonnenberg B, Hagtvedt R, et al. Adverse events associated with medium- and long-term use of opioids for chronic non-cancer pain: an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017;10:CD012509 Cochrane library systematic review of 16 other Cochrane reviews. Compared to placebo, opioid use associated with an absolute event rate of 78% for any side effect (including constipation, dizziness, nausea, and more serious side effects) and 7.5% for any serious side effect. Known side effects such as addiction, mood disorders, respiratory depression, and sleep disturbance were not included in the reviewed articles. PubMedGoogle Scholar
- 41.Ghodke A, Barquero S, Chelminski PR, Ives TJ. Short-acting opioids are associated with comparable analgesia to long-acting opioids in patients with chronic osteoarthritis with a reduced opioid equivalence dosing. Pain Med. 2017.Google Scholar
- 49.Cowan DT, Wilson-Barnett J, Griffiths P, Vaughan DJ, Gondhia A, Allan LG. A randomized, double-blind, placebo-controlled, cross-over pilot study to assess the effects of long-term opioid drug consumption and subsequent abstinence in chronic noncancer pain patients receiving controlled-release morphine. Pain Med. 2005;6(2):113–21.CrossRefGoogle Scholar
- 51.Centers for Disease Control and Prevention. Common elements in guidelines for prescribing opioids for chronic pain. Atlanta: US Department of Health and Human Services, CDC; 2015.Google Scholar
- 54.• Eccleston C, Fisher E, Thomas KH, Hearn L, Derry S, Stannard C, et al. Interventions for the reduction of prescribed opioid use in chronic non-cancer pain. Cochrane Database Syst Rev. 2017;11:CD010323 An update of the 2013 Cochrane library systematic review evaluating the effectiveness of acupuncture, mindfulness, and CBT at decreasing opioid requirement in patients with chronic non-cancer pain. Overall, results were mixed, with reductions of opioid in both active and control arms. The authors were unable to conclude that any method was superior to the desired outcome. PubMedGoogle Scholar
- 55.Boseley S. Prescription of opioid drugs continues to rise in England. The Guardian. 2018.Google Scholar
- 56.Midlov P. Tapering of long-term opioid therapy in chronic pain population. RCT With 12 Months Follow up. Identification No. NCT03485430. 2018. [cited; Available from: https://ClinicalTrials.gov/show/NCT03485430.