Overprescribing of opioid painkillers has caused harm to many people. Problems include addiction, loss of social functioning and increasingly, though still relatively uncommonly in the UK, to death.
Concerns have been raised about deaths associated with tramadol in particular. I’ve written before about the lack of evidence of effectiveness for opiates in chronic pain, but it is hard for clinicians to resist the slippery slope of initiating and then increasing opioid strength or dose when faced with a patient reporting pain. There is an expectation that pain needs painkillers – there is arguably a culture of prescribing opiates for chronic pain. But that’s just common sense – right?
Let’s not be so fast. Recently pain specialists and neurologists have become more vocal about warning against prescribing for chronic non-cancer pain. The American Academy of Neurology has just issued a review and position paper on the subject written by Dr Gary Franklin of the University of Washington.
The driver behind the initiative is the 100,000 Americans who have died, directly or indirectly, from prescribed opiates in the US since the late 1990s. This is more than died from RTAs and firearms. This is far more than the number of US military personnel who died in the Vietnam war. It truly is an epidemic – a national tragedy – and it looks like it is one which could have been avoided or one that could at least be ameliorated. It is one that is caused by non-evidence based prescribing.
Diversion and inappropriate use of opioids is a problem. The paper illustrates the point:
In one population-based study in Ontario, Canada, of all deaths attributable to opioids during 2006–2008, 7% of patients had died from opioids diverted from friends or family, and 19% had inappropriately self-administered (e.g., inhaled, injected). A greater proportion of deaths may be associated with diversion in rural states.
Risk to benefit balance
The effectiveness of opiods in chronic pain is uncertain and this is, as the paper graphically illustrates, grossly outbalanced by the down sides:
- Overdose morbidity
- Serious adverse events
- Lifelong disability
- Loss of family and community
The paper makes some clear best-practice recommendations which I’ll paraphrase:
- Have an agreement with the patient at the outset that identifies the risks and outlines the patient’s responsibilities
- Identify current or past substance misuse
- Identify risk of depression
- Use urine toxicology prudently (identify diversion or misuse of other substances). Screen before starting.
- Use tools to track pain and function and monitor tolerance
- Track the amount of opioids used daily- converted to the equivalent dose of morphine (MED)
- Get further help if the MED reaches 80-100mg and there is no significant pain improvement.
- Use a programme available in most states to monitor ‘all sources of controlled substances’.
A different approach to pain
These recommendations are solid though I would have liked them to include something that is mentioned elsewhere in the paper – to address pain in a holistic way. Why is pain always seen as something to be instantly medicated, solved by a pill? Pain is a complex symptom with biological, psychological and social influences. Franklin writes:
In addition payers need to offer adequate payment incentives for treatment alternatives to the opioid prescription for acute, subacute, and chronic pain. Cognitive–behavioral therapy, structured exercise, spinal manipulation, and interdisciplinary rehabilitation, although proven to be moderately effective in treating subacute and chronic low back pain, are often either not available or not adequately funded.
A collaborative care model for the care of patients with chronic pain, not unlike similar models aimed at chronic disease management of diabetes and other con- ditions, should be a crucial element in the evolving health care reform environment.
It seems likely that, in the long run, the use of opioids chronically for most routine conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not prove to be worth the risk.
And the risk for those with a vulnerability to addiction is significant. Prescribing for pain is a common route of entry into opioid addiction.
Prescribers and patients
But we have a lot of work to do to change the prevailing culture. Time Magazine picked up on this paper in a recent article. They highlight the challenges around changing the culture of prescribers:
In 2003, Dr. Jane Ballantyne and Dr. Jianren Mao, then at Massachusetts General Hospital and Harvard Medical School, published a review of the existing data on opioid use for chronic pain in the New England Journal of Medicine. It was among the first studies to highlight the fact that the skyrocketing number of prescriptions was doing little to actually reduce reports of chronic pain.
“The real problem is physicians who are practicing with the best intentions and not understanding what the limited role of opiates is,” says Ballantyne, now a professor of anesthesiology and pain medicine at the University of Washington. “For 20 years they have been taught that everybody deserves an opiate, because they really don’t know what else to do. It’s a cultural thing and it’s hard to reverse that.”
In the Time feature Ballantyne continues:
“In this country we expect everything to be fixed, and that doctors have the answer and can take pain away… We shouldn’t be resorting to pills as a first resort; they should very much be a last resort”
Franklin, G. (2014). Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology Neurology, 83 (14), 1277-1284 DOI: 10.1212/WNL.0000000000000839