Pain Management
AAN Warns Against Opioids in Chronic Noncancer Pain
Published: Sep 29, 2014
By Kristina Fiore, Staff Writer, MedPage Today
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
Discussant: Melinda Lawrence, MD
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Action Points
A position paper from the American Academy of Neurology suggests that the risks for chronic opioid therapy for some chronic conditions such as headache, fibromyalgia, and chronic low back pain likely outweigh the benefits.
It also suggests that if daily dosing exceeds 80 to 120 mg/d of a morphine-equivalent dose, consultation with a pain management specialist is recommended.
The risks of opioids far outweigh their benefits in chronic pain conditions such as headache, fibromyalgia, and lower back pain, according to a new policy statement from the American Academy of Neurology.
The statement lists several best practices -- including checking a prescription data monitoring program (PDMP) before prescribing opioids -- and calls for primary care doctors to refer chronic pain patients to specialists if they are taking daily doses of 80 to 120 mg morphine-equivalent per day.
Gary Franklin, MD, of the University of Washington in Seattle, is the sole author of the statement, published in Neurology. Franklin is known for bringing to light a sharp increase in opioid overdose deaths in his tenure at Washington state's workers' compensation program -- which many say sparked the nation's awareness of a rising prescription opioid epidemic.
"The evidence of harm is high, and the effectiveness is low," Franklin told MedPage Today, calling attention to a graphic in the statement that shows the imbalance. "That is the whole story."
AAN is the first national medical association to adopt a policy statement regarding opioids. Franklin's home state has adopted dosing guidelines, which call for doctors to refer to pain management specialists when daily doses hit 120 mg morphine-equivalent -- a policy that the CDC has also endorsed.
The Ohio state medical board has also issued new guidelines with a cutoff of 80 mg/day morphine-equivalent, Franklin noted. But no other national medical societies have issued such policies or guidance.
Franklin said the Washington state guidelines are being re-evaluated, noting that the cutoff of 120 mg/day was determined in 2006 using the best evidence available at the time. Several papers have been published since then, showing significantly increased risks of overdose among among patients taking 100 mg/day and, in some cases, much less -- hence the 80 to 120 mg/day used in the AAN policy statement.
"For doctors, it's about having a number in your head. It doesn't matter if it's 80 or 120," Franklin said. "It puts an anchor in the physician's head that there could be danger."
Policy Statement
The paper notes that there have been more than 100,000 opioid-related deaths since the late 1990s, acknowledging what the CDC and other public health agencies have dubbed an epidemic of opioid abuse.
In a review of the literature, Franklin notes that there's little evidence for use of opioid therapy for longer than 16 weeks, and studies have shown that they are not effective for migraine, other types of headache, or generalized pain.
Franklin also delivered a history of the opioid epidemic, starting with the sentinel paper by doctors Kathleen Foley and Russell Portenoy in 1986 that opened the door to more liberal prescribing of opioids. That subsequently led to pain advocacy groups to lobby state medical boards and legislatures to enable liberalized prescribing, and by 2010 the CDC was calling for the brakes on an epidemic that claimed 16,651 deaths that year alone. (In the latest data, from 2011, that number stands at around 17,000).
"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," Franklin wrote in the paper. "However, even for more severe conditions, such as destructive rheumatoid arthritis, sickle-cell disease, severe collagen disease, or severe neuropathic pain, prescribers need specific guidance on dosing, publicly available brief tools to effectively screen patients for risk, and guidance on how to monitor patients for early signs of severe adverse events, misuse, or opioid use disorder."
The statement lists several best practices, including accessing state PDMP data before prescribing these drugs, routine screening for substance abuse, and avoiding dose escalation above 80 to 120 mg/day morphine-equivalent.
It notes that some alternative pain therapies may be cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation.
Physicians should also take great care when trying to taper "legacy" patients who have been on doses above 120 mg/day for longer periods of time.
Pain Community Reaction
Bob Twillman, PhD, director of policy and advocacy for the American Academy of Pain Management, said the paper recognizes the toll exacted by opioid abuse but fails to acknowledge the problem of inadequately treated chronic pain.
"In general, I think the recommendations for clinical practice are sound and reflect best practices, although I do think they are a bit too black-and-white for the largely gray world of pain management," Twillman told MedPage Today. (Read his full response here.)
Lynn Webster, MD, a past-president of the American Academy of Pain Medicine, said the position statement doesn't add anything new to what is already known about opioid risks and benefits.
"AAN recognizes opioids may be an important therapy for a select subset of patients but are associated with significant risks. This is consistent with the views of most other professional organizations," Webster told MedPage Today. "I believe the overall message is that people in pain need access to safer and more effective therapies than opioids."
Webster's former pain practice, Lifetree Pain Clinic in Salt Lake City, was under federal investigation following reports of patient overdose deaths, but Webster told MedPage Today that the inquiry as since been dropped.
Melinda Lawrence, MD, a pain management physician at University Hospitals Case Medical Centers, who was not involved in the policy statement, said it "reaffirms what the literature has been showing for a long time regarding opioid use in chronic noncancer pain -- that the risks outweigh the benefits."
"I do believe that clinicians have been tempering their use of opioids," Lawrence said. "We see that physicians are definitely more reluctant to prescribe opioids. They want [the opinion of pain specialists] before prescribing, or to see if there are other treatment modalities."
Cluster of Attention to Opioids
The policy statement's publication coincided with two events in Washington, D.C., involving the use of opioids in pain management.
On Sunday, activists marched on the Washington Mall in a FedUp! Rally against opioid overprescribing, and a 2-day meeting organized by the NIH bringing together key stakeholders in pain management began on Monday. The panel was charged with evaluating the state of the evidence regarding opioid prescribing.
Franklin said the timing was purely accidental.
He said the AAN's patient safety subcommittee had requested a review of the science and policy issues more than a year ago, and that the final paper was highly vetted, with review from several committees within AAN, including the practice committee, the patient safety committee, and the board of directors.
