For most chronic pain, neurologists declare opioids a bad choice
Patients taking opioid painkillers for chronic pain not associated with cancer -- conditions such as headaches, fibromyalgia and low-back pain -- are more likely to risk overdose, addiction and a range of debilitating side effects than they are to improve their ability to function, a leading physicians group declared Wednesday.
The long-term use of opioids may not, in the net, be beneficial even in patients with more severe pain conditions, including sickle-cell disease, destructive rheumatoid arthritis and severe neuropathic pain, the American Academy of Neurologists opined in a new position statement released Wednesday.
But even for patients who do appear to benefit from opioid narcotics, the neurology group warned, physicians who prescribe these drugs should be diligent in tracking a patient’s dose increases, screening for a history of depression or substance abuse, looking for signs of misuse and insisting as a condition of continued use that opioids are improving a patient’s function.
In disseminating a new position paper on opioid painkillers for chronic non-cancer pain, the American Academy of Neurology is hardly the first physicians group to sound the alarm on these medications and call for greater restraint in prescribing them.
But it appears to be the first to lay out a comprehensive set of research-based guidelines that outline which patients are most (and least) likely to benefit from the ongoing use of opioids -- and what practices a physician should follow in prescribing the medications for pain conditions.
The statement would govern the prescribing of morphine, codeine, oxycodone, methadone, fentanyl, hydrocodone or a combination of those drugs with acetaminophen. It was published Wednesday in the journal Neurology.
The American Academy of Neurology’s position statement also urges physicians to work with officials to reverse state laws and policies enacted in the late 1990s that made the prescribing of opioid pain medication vastly more commonplace.
The position paper notes that despite a national epidemic of painkiller addiction that has claimed more than 100,000 lives in just over a decade, many of the laws and practices adopted in the late 1990s remain unchanged. It adds that prescription drug monitoring programs -- online databases that would allow physicians to quickly check on all controlled substances dispensed to a patient -- “are currently underfunded, underutilized and not interoperable across state lines or healthcare systems.”
The result is that patients’ tendency to develop a tolerance for opioid drugs -- and to require ever-higher doses to achieve pain relief -- often go unnoticed. The result is not only addiction and misuse, but an escalating risk of accidental overdose, since opioid narcotics depress breathing and, especially when mixed with alcohol or other sedative drugs, can prove deadly.
In the age group at highest risk for overdose -- those between 35 and 54 -- opioid use has vaulted ahead of firearms and motor vehicle crashes as a cause of death.
The American Academy of Neurology statement cites studies showing that roughly half of patients taking opioids for at least three months are still on opioids five years later. Research shows that in many cases, those patients’ doses have increased and their level of function has not improved.
In addition to screening patients for depression or past or present drug abuse, physicians prescribing a long-term course of opioids to patients with pain should draw up an “opioid treatment agreement” which sets out the responsibilities of patients and physicians. Physicians should track dose increases and assess changes in a patient’s level of function, and if a specific daily dose is reached (a “morphine equivalent dose” of 80-120 mg) and a patient’s pain is not under control, doctors should seek the help of a pain specialist.
The statement also recommends against prescribing any benzodiazepines or other sedating drugs to patients who take opioid painkillers. And it recommends the “prudent use” by physicians of random urine testing for patients taking opioids to detect misuse of the drugs or abuse of other, non-prescribed drugs. When a physician takes on the care of a patient who has taken opioid painkillers for more than three months and has aberrant behavior or a history of overdose, he or she should consider a trial aimed at weaning the patient off such medication.
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