Accurate Education - Politics of Pain

“That’s another fine mess you’ve gotten us into!”
– Oliver Hardy

The Politics of Pain

updated 4/1/2018

To identify and contact your state senators and congressmen:

www.legis.la.gov/legis/FindMyLegislators

The management of chronic pain, particularly as related to the use of opioids, has risen to the forefront of public attention as a result of the perceived “epidemic” of opioid abuse and climbing numbers of opioid-related overdose deaths. In the past decade, while the death rates for the top leading causes of death such as heart disease and cancer have decreased substantially, the death rate associated with opioid pain medication has increased significantly.

This trend has resulted in great concern and has resulted in a massive and growing effort to reduce these deaths. But, unfortunately, this response to the problem has had many unintentional and negative consequences. While the perfect solution remains elusive, it is important to truly understand what the problem actually is before hoping to solve it.

See below.

To Start With

Any discussion relative to the concern of opioid prescribing must include a thorough understanding of the problems of opioid addiction, abuse and misuse. Publication after publication alarm us about the prevalences and consequences of opioid “abuse” in this country. However, the basis of understanding any problem requires meaningful communication regarding that problem and accurate communication requires consensually shared definitions of the terms and concepts appropriate to understanding that problem.

From 1999 to 2014, more than 165,000 persons died from overdose related to opioid pain medication in the United States. In 2014, more than 14,000 people died from overdoses involving prescription opioids. Studies indicate, however, that the rate of opioid abuse has flattened or decreased from 2011 through 2013 and it is believed that this trend has continued.

Indeed, 14,000 deaths is lamentable. However, it is of value to place this in perspective – according to CDC statistics from their 2015 health report (Health-United States 2015), the ten leading causes of death in the U.S. in 2014 are as follows:

Heart disease: 614,348
Cancer: 591,699
Chronic lower respiratory diseases: 147,101
Accidents (unintentional injuries): 136,053
Stroke (cerebrovascular diseases): 133,103
Alzheimer’s disease: 93,541
Diabetes: 76,488
Influenza and pneumonia: 55,227
Nephritis, nephrotic syndrome, and nephrosis: 48,146
Intentional self-harm (suicide): 42,773

The Recent History of Pain Management

In 1996, the American Pain Society (APS) introduced the phrase “pain as the 5th vital sign” in response to the recognition that the medical community was failing to adequately assess and treat pain. In 1999, a survey released by the American Pain Society revealed that more than four out of every 10 people with moderate to severe chronic pain received inadequate pain control and more than 50 percent had been in pain for more than five years. In 2001, in “A Special Message” from the Director of the American Academy of Pain Management – Kathryn Weiner, PhD, pain was described as a “silent epidemic affecting 75 million Americans.”

According to an Institute of Medicine report released in 2011, one in three Americans experiences chronic pain—more than the total number affected by heart disease, cancer, and diabetes combined. In Europe, the prevalence of chronic pain is 20-30%. By 2014, the number of Americans with chronic pain had risen to more than 100 million, with 1.5 billion people affected worldwide. Consequently, the pendulum swing over the previous two decades resulted in medical professionals increasing their prescribing of opioids in an effort to more effectively treat pain. This increased prescribing, including over-prescribing, is believed to be a major contributing factor in this expanding death rate. The pendulum is now swinging back.

It has been estimated that chronic pain accounts for nearly half of all primary care visits (McCarberg BH. Postgrad Med. 2011;123:119-130). But according to studies evaluating primary care physicians (PCPs) and pain management, when dealing with patients with chronic pain:

(1) PCP feelings regarding the treatment of chronic pain include frustration, lack of gratification, and guilt (Matthias MS, et al. Pain Med. 2010;11:1688-1697),

(2) Only 34% of PCPs are comfortable treating patients with chronic pain (O’Rorke JE, et al. Am J Med Sci. 2007;333:93-100)

(3) And only 15% enjoy treating them. (Potter M, et al. J Fam Pract. 2001;50:145-151).

So who is treating this pain?

As of 2010, (Breuer B, et al. South Med J. 2010;103:738-747.), the breakdown is as follows:

PCPs treat 52%

Chiropractors treat 40%

Acupuncturists treat 7%

Pain specialists treat 2%

At this junction in time, the pain community is struggling to identify appropriate and efffective means of treating pain including the safe use of opioids. This struggle has polarized not only the medical community but society at large in opinions and beliefs about determining a course of action. As often occurs in arenas of this magnitude and despite well-minded intentions, misinformation and emotional responses lead to decisions and recommendations that ultimately result in unintended outcomes.

In what one author, Stephen Ziegler JD, refers to as our current environment of “Opioid McCarthyism,” circumstances have lead to an atmosphere of fear and reluctance to effectively manage pain with opioids. Physicians are confronted with a sea of conflicting information regarding the use of opioids based on an overwhelming lack of definitive research to guide their pain management. To make matters worse, physicians are intimidated by fear of regulatory actions or being perceived as “drug pushers.”

The predictable outcome of this maelstrom has been a reduced willingness for physicians to treat pain and a worsening availability of accessible pain management for patients with chronic pain. And, in a recent move, the AMA voted to remove pain as the fifth vital sign. While this suggests one of the AMA’s “solutions” to the opioid problem is to stop asking patients about their pain, the argument otherwise appears to center on how this fifth vital sign has been hijacked by insurers and inappropriatedly incorporated into the management of pain. That being said, concern remains that pain will again become under-assessed and under-treated.

Pain management, prescription opioid mortality, and the CDC:

Is the devil in the data?

When confronted with the alarming statements and statistics commonly presented in news stories, the question must be asked, “Are they factually accurate, or do they reflect a particular agenda – a campaign that fails to recognize the complexity of the issues, the factors, sources, and problems that once identified could help forge effective solutions?”

Many of the recent statistics asserted by the press are not only inaccurate and misleading, they also impair the ability of people to understand the complexity of the problem in order to create meaningful and appropriate solutions. While prescription opioids do play a part in the current crisis, illicit opioids such as heroin and illicitly manufactured fentanyl, not prescription opioids and overprescribing, are currently the primary sources behind the increase in unintentional overdose deaths in the United States. Ignoring this critical distinction has not only compromised efforts to improve the problem but, instead, it has had a severe, negative impact on the legitimate management of pain with opioids. This compromise to legitimate opioid pain management ultimately compounds the crisis of unintentional deaths by driving more undertreated pain patients to the use of illiict opioids.

It is often implied that people prescribed opioids for pain frequently abuse their pain medications and subsequently become addicted. A structured review study published in 2008, ” What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors,” offered revealing statistics.

Regarding addiction to opioids, a summary review of 24 studies revealed that only 3.3% of patients prescribed opioids for chronic pain over a span of just over 2 years developed an addiction to their opioids. In studies that preselected for chronic pain patients that did not already have a history of addiction before being prescribed opioids, the overall percentage dropped to 0.2%.

Regarding aberrant drug-related behavior, including abuse and misuse, a summary review of 17 studies revealed that only 11.5% of patients exhibited aberrant behavior over 10.8 months. In studies that preselected for chronic pain patients that had no previous history of aberrant drug-related behaviour before being prescribed opioids, the overall percentage dropped to 0.59%.

While the statistics relating percentages of patients prescribed opioids that evolve into opioid addiction may vary quite a bit depending on the source, a recent publication released in July, 2017 by the authoritative Substance Abuse and Mental Health Services Administration (SAMHSA) of the U.S. government reveals the percentages regarding misuse of opioids.

Of the 91.8 million patients prescribed opioids for pain, only 12.5% (one in eight people) misused their opioids. Of this 12.5%, 63.4% misused their opioids to manage their pain; only 11.7% of people were reported to misuse opioids to “feel good or get high.”

In other words, only 1.46% of patients prescribed opioids for pain take them to “feel good or get high.” and only 0.3% take them because they feel “hooked” to them. Furthermore, a significant number of patients reporting their motivation to “feel good” may well have been responding to their relief of pain.

For those reporting their motivation to “feeling hooked or having to have them,” a significant number of these patients may have indicated doing so out of feeling dependent on their pain medications to function and enjoy quality of life, not based on addiction. It is very common for patients to feel “addicted” and even report themselves as “addicted,” when in fact they are expressing opioid physical dependence and do not meet criteria for addiction, which is a very different entity.

For an excellent review of our current national circumstance regarding the politics of pain including an informed set of facts behind the clamor, see the editorial below, published in October 2017:

Pain Management Rx Opioid Mortality and CDC

Terms and Definitions

In this world of opioid management and substance abuse, one glaring issue underscores our understanding of the problems we hope to improve. When it comes to the terms “opioid abuse” and “opioid misuse,” there is absolutely no consensus regarding their definitions which are as varied as there are individuals using them. Even worse, the surveys used in the studies and the studies themselves usually fail to assess the motivations leading to the aberrant behaviors subseqently labeled as abuse or misuse. Too often the term “abuse” is applied to any inappropriate urine drug screen (UDS) result, often not even confirmed, with no exploration whatsoever as to the variables leading to the aberrant UDS. These variables are critical to the understanding of the behaviors we wish to modify and obviously dictate individualized approaches to treatment.

In 2015, SAMHSA (Substance Abuse and Mental Health Services Administration) provided a revised definition of “misuse” of prescription drugs, defined as use “in any way a doctor did not direct you to use it.” Examples include “Using it without a prescription of your own, using it in greater amounts, more often, or longer than you were told to take it, or using it in any other way a doctor did not direct you to use it.” This definition of misuse was introduced in their 2015 annual National Survey on Drug Use and Haealth (NSDUH) and differed from the previous term, “nonmedical use,” in the 2014 NSDUH which combined a behavior (use of a drug that was not prescribed for) and a motivation (or use only for the experience or feeling the drug caused). The 2014 definition did not include overuse of a prescription drug which is an important consideration in understanding medication behavior.

The discontinued use of the previous term “nonmedical use” accompanied by the replacement term “misuse” implies potential breaks in comparability with many statistal estimates of prevalence from prior years, leading to misplaced, erroneous conclusions.

What these statistics fail to explore is the motivation of use of opioids and other prescription drugs. To understand the mechanisms of behavior that lead to problematic and hazardous use including addiction, it is vital to understand motivation of use.

Until the clinical and research community come to a consensus of how to define our concerns, we will fail to adequately understand or respond to the problems. For the purposes of this web site, the following definitions apply:

Medication Abuse:

“Medication Abuse” is defined as the use of a drug for purposes other than as indicated or prescribed. “Purposes other than as indicated or prescribed” include using a medication such as a pain medication for sleep, anxiety, to improve mood or to get high.

Medication Misuse:

“Medication Misuse” is defined as the use of a drug for purposes as indicated or prescribed, but at doses other than as indicated or prescribed including use in greater amounts, more often or longer than told to take a drug, or use in any way not directed by a doctor. Medication misuse includes taking a prescription medication as previously or routinely prescribed, but without a current prescription.

See: Opioid Abuse and Misuse

Politics of Pain

In an effort to address the opioid problem, the Center for Disease Control (CDC) recently released the “CDC Guideline for Prescribing Opioids for Chronic Pain“ to provide recommendations for the prescribing of opioid pain medication by primary care clinicians for chronic pain. While controversial amongst physicians and the public alike, the recommendations presented in this guideline are likely to shape the direction of pain management to come and will affect both patients and prescribing physicians. As such, it is advisable that pain patients familiarize themselves with the content of the 2016 CDC guideline.

Comments

The 2016 CDC Guideline opens with a collection of alarming statistics as summarized above, focusing on the increased prescription opioid related deaths over the last 15 years and the “epidemic” of opioid abuse and addiction. However, it is meaningful to place these numbers in context. To start with, the numbers reflect “opioid-related” deaths and is not the same as opioid-caused deaths or even the same as deaths in which opioids contributed to the deaths, which is a subtle but important distinction. The statistic numbers are derived from death certificates and ICD codes that do not allow for distinguishing overdoses in which the opioid was the primary drug (present at a concentration sufficient to have caused the death alone regardless of other drugs detected) or additive (the opioid was at a concentration not sufficient to have caused the death alone but acted in an additive manner with other drugs to have caused the death) or incidental (the opioid was present but at a concentration non-contributory to the death ).

Opioid-related deaths are rare even for patients who take opioids every day for years. The CDC cites ‘‘a recent study of patients aged 15-64 years receiving opioids for chronic noncancer pain” who were followed for up to 13 years. The researchers found that ‘‘one in 550 patients died from opioid-related overdose,” which is a risk of less than 0.2 percent. And, again, the vague term ” opioid-related overdose” is used.

Additionally, the identification of a “prescription” drug implies the drug was prescribed to the overdose victim but does not distinguish between illicitly obtained prescription drugs nor “prescription” drugs such as fentanyl that are illicitly manufactured and are a growing source of overdose deaths. Furthermore, it is well established that heroin use and overdose is on the rise. Heroin has an extremely rapid half-life of 2-6 minutes, and is metabolized to 6-acetylmorphine and morphine. The half-life of 6-acetylmorphine is 6-25 minutes and is not detectable in the blood within 2 hours of intranasal or intravenous use. Even urinary detection of 6-acetylmorphine is limited to hours after use. As a result of this rapid metabolization of heroin, in a matter of hours the only evidence of heroin use is the presence of morphine which will then be reported as a prescription opioid related overdose, thus potentially inflating the number of “prescription opioid” related deaths.

To investigate the actual role of prescription opioids as cause or definitie contributor to death, a recent study (2016) evaluated opioid overdose deaths in North Carolina in 2010. Cases were only included when opioids were primary or additive as causes of overdose death. Only 51% of the decedents actually had an active prescription for the opioid at the time of death, indicating that essentially half of the deaths consisted of illicit use, not prescribed. Additionally, 24% of the decedents did not have any prescribed opioid within the preceding year. These findings are similar to Washington findings in which only 59% among methadone overdose decedents and 43% among other opioid overdose decedents had an active opioid prescription in the week prior to death. Of these opioid-related overdose deaths in N.C., more than half (61.4%) involved the presence of benzodiazepines in addition to the opioid. Alcohol was involved in 12.2% of the opioid overdose deaths.

Another study (2012) looking at unintentional prescription opioid overdose deaths in Utan in 2008-2009, showed that reported potential misuse prescription pain medication in the year prior to their death was high (e.g., taken more often than prescribed [52.9 %], obtained from more than one doctor during the previous year [31.6 %], and used for reasons other than treating pain [29.8 %, almost half of which “to get high”]).

The significance of these studies is that it highlights the fact that the circumstances and details regarding overdose deaths is important and the risk of prescription opioid overdose death is greatly reduced when one is actively under the appropriate care of a prescribing physician and not in conjunction with the use of benzodiazepines or alcohol.

Unfortunately, the study did not look at the breakdown of patients prescribed opioids by pain specialists vs. other physicians. Presumably, physicians – and patients – with more extensive training in opioid management will provide safer prescribing practices and consequently fewer prescription opioid-related overdose deaths. In a recent study (2015) that investigated unintentional prescription opioid overdose deaths, among 1,457 patients who were last seen in outpatient settings, patients were seen more in mental health (26%) and primary care clinics (31%) compared to substance use disorder (8%) or pain clinics (3%), in the month before death.

Quoting statistics such as the “14,000” opioid prescription-related deaths is inflammatory and politicized because it generates the implication that these deaths were directly caused by physician prescribing practices which upon further evaluation as shown above is not accurate. This inaccuracy fans the fires of controversy and potentially misdirects efforts for identifying solutions to the problem. Furthermore, it impacts patient confidence in opioid pain management which remains the most effective medication for many thousands of people who’s quality of life has been eroded by chronic pain.

CDC – The State of Knowledge Regarding Opioid Pain Management

As the medical community seeks to find safer, more effective means of managing pain with opioids, a fair amount of research has attempted to provide answers regarding prescribing opioids. The 2016 CDC Guidelines investigated how current research answers 3 fundamental questions:

What is the effectiveness of long-term opioid therapy versus placebo, no opioid therapy, or nonopioid therapy for long term (≥1 year) outcomes related to pain, function, and quality of life, and how does effectiveness vary according to the type/cause of pain, patient demographics, and patient comorbidities (Key Question 1).
What are the risks of opioids versus placebo or no opioids on abuse,addiction, overdose, and other harms, and how do harms vary according to the type/cause of pain, patient demographics, patient comorbidities, and dose (Key Question 2).
What is the comparative effectiveness of opioid dosing strategies (different methods for initiating and titrating opioids; immediate-release versus extended release/long acting (ER/LA) opioids; different ER/LA opioids; immediate-release plus ER/LA opioids versus ER/LA opioids alone; scheduled, continuous versus as-needed dosing; dose escalation versus dose maintenance; opioid rotation versus maintenance; different strategies for treating acute exacerbations of chronic pain; decreasing opioid doses or tapering off versus continuation; and different tapering protocols and strategies) (Key Question 3).

To assess the quality of the research performed to answer these questions, the CDC stratified the quality level of evidence into 4 GRADE types:

Type 1 evidence indicates that one can be very confident that the true effect lies close to that of the estimate of the effect
Type 2 evidence means that the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different
Type 3 evidence means that confidence in the effect estimate is limited and the true effect might be substantially different from the estimate of the effect
Type 4 evidence indicates that one has very little confidence in the effect estimate, and the true effect is likely to be substantially different from the estimate of the effect.

“When no studies are present, evidence is considered to be insufficient.” – CDC

“According to their GRADE methodology, a particular quality of evidence does not necessarily imply a particular strength of recommendation.” (Comment ??- eeMD).

CDC Review of the Evidence Based on Current Research

“The overall evidence base for the effectiveness and risks of long-term opioid therapy is low in quality per the GRADE criteria.”

Thus, the CDC conducted additional literature searches for contextual evidence to update the evidence review to include more recently available publications. More details on the contextual evidence review are provided in the CDC – Contextual evidence review.

Comment

First, understand that the statement often presented by the ignorant that “there is no evidence of benefit from the chronic use of opioids for chronic noncancer pain” is simply wrong. In truth, there is a lack of quality research studies that address this question, but no lack of evidence. Evidence by it’s very definition includes the testimony of a witness. Any physician who has treated chronic pain patients with opioids will attest to the benefit the majority of patients obtain. Milllions of chronic noncancer pain patients attest to their benefit. There is no lack of evidence. There are simply few well designed research studies.

Additionally, the CDC conclusion of “low quality evidence” is not shared by many experts in pain management. In the ASIPP Guidelines for Responsible Opioid Prescribing – 2012 it is noted that:

“Among the 5 studies described as observational or open-labeled, the results were only indicative at best, since their design implied less methodological rigor than seen with RCTs. In 4 of these studies, a statistically significant improvement in the overall Quality of Life (QOL) was seen with long-term opioid treatment. Only one of the studies failed to detect an overall change in QOL.

Thus, Devaulder et al concluded that there was both moderate/high quality and low quality evidence suggesting that the pain relief elicited by long-term (defined as greater than 6 weeks duration of opioid treatment) was accompanied by improvement in QOL. They also concluded that owing to the heterogeneity of the included studies, in terms of the population studied, study designs used, and outcome measures assessed and the methods used to assess them, it was not possible to determine the average magnitude of this QOL improvement. Based on these findings, the authors postulated that if an appropriate dose level is chosen for each patient, on an individual basis, pain relief elicited by long-term opioid treatment might offset the impact of common side effects of treatment to evoke an overall improvement in a patients’ well-being.”

CDC Findings for the 3 Key Questions

Effectiveness of Opioids (Key Question 1)

Although opioids can reduce pain during short-term use, the clinical evidence review found insufficient evidence to determine whether pain relief is sustained and whether function or quality of life improves with long-term opioid therapy. No study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy for chronic pain evaluated long-term (≥1 year) outcomes related to pain, function, or quality of life.

“The body of evidence for Key Question 1 is rated as insufficient.”

Harms of Opioids (Key Question 2)

“The body of evidence for Key Question 2 is rated as type 3”

(Type 3 evidence means that confidence in the effect estimate is limited and the true effect might be substantially different from the estimate of the effect).

While benefits for pain relief, function, and quality of life with long-term opioid use for chronic pain are uncertain, risks associated with long-term opioid use are clearer and significant. Based on the clinical evidence review, long-term opioid use for chronic pain is associated with serious risks including increased risk for opioid use disorder, overdose, myocardial infarction, and motor vehicle injury.

Opioid-related Deaths and Morphine Equivalency

It was concluded that higher doses of opioids is associated with increased risk of abuse and of serious overdose. Dosing of opioids is standardized by comparing a milligram dose of an opioid with the equivalend milligram dose of morphine. If an opioid is twice as strong as morphine, than it’s morphine milligram equivalents (MME) is 2 and a dose of 40mg/day of that opioid would be 80 MME/day.

For more information about morphine equivalency, see Medication for Pain – Opioids.

Research suggests the dose-dependent association with risk for overdose death relative to 1–19 Morphine-equivalent dose (MME)/day, the adjusted odds ratio (OR) was:

1.32 for 20–49 MME/day
1.92 for 50–99 MME/day
2.04 for 100–199 MME/day
2.88 for ≥200 MME/day

In other words, when the MME dosing is between 20 and 49, the risk of abuse/overdose is about 30% higher, about twice as high when MME dosing is between 50 and 200mg/day and nearly 3x as high when ME is more than 200mg/day. While not noted by the CDC Guidelines, recent research on prescription opioid overdose deaths in North Carolina in 2014 indicates that while the risk ratios of overdose risk climb somewhat steeply between 10 and 200, the rate of increased risk lessens as as MME exceeds 200.

Comment

What does not appear to have been evaluated in arriving at these statistics is a stratification of the overdose risk in context with how long a duration of treatment at a particular MME level. Presumably the risk of overdose would be higher in transition periods to higher MME than in patients at a same MME for an extended period of time.

Additionally, other variables come into play besides looking simplistically at a simple ME value. Those individuals requiring higher opioid doses also may be at greater risk for comorbidities including depression, conditions related to increased oxidative stress such as diabetes and cardiovascular disease and sleep apnea, any or all of which may play a role in the risk of death. The majority of overdose deaths occur at night and it is known that the combination of opioids and untreated sleep apnea raise the risk of unintentional opioid-related deaths in what is likely to be dose-dependent, especially in transitioning to higher opioid doses.

Also, it should be emphasized that there are many variables that contribute to how and why a patient arrived at being prescribed higher MME of opioids. These variables are very likely to be significant contributors to the increased risks associated with high MEE doses. While the MME number itself does suggest independent risk, it is extremely important to evaluate the many other contributing variables that are likely to be as important as the MME number itself. This is especially true when applying risk assessment on an individual patient basis.

Opioid Dosing Strategies (Key Question 3)

“The body of evidence for Key Question 3 is rated as type 4”

(Type 4 evidence indicates that one has very little confidence in the effect estimate, and the true effect is likely to be substantially different from the estimate of the effect.)

Immediate-Release Opioids versus Extended Release/Long Acting (ER/LA) Opioids Strategies

For initiation and titration of opioids, a 2014 report found insufficient evidence from three fair-quality, open-label trials to determine comparative effectiveness of ER/LA versus immediate-release opioids for stable pain control.

Evidence on other comparisons related to opioid dosing strategies (ER/LA versus immediate- release opioids; immediate-release plus ER/LA opioids versus ER/LA opioids alone; scheduled continuous dosing versus as-needed dosing; or opioid rotation versus maintenance of current therapy; long-term effects of strategies for treating acute exacerbations of chronic pain) was not available or too limited to determine effects on long-term clinical outcomes.

Summary of CDC Recommendations

The CDC recommendations were based on the following assessments:

No evidence shows a long-term benefit of opioids in pain and function versus no opioids for chronic pain with outcomes examined at least 1 year later (with most placebo-controlled randomized trials ≤6 weeks in duration). (Comment – “The absence of evidence is not evidence of absence” – eemd)
Extensive evidence shows the possible harms of opioids (including opioid use disorder, overdose, and motor vehicle injury).
Extensive evidence suggests some benefits of nonpharmacologic and nonopioid pharmacologic treatments compared with long-term opioid therapy, with less harm.

CDC Recommendations (selected)

Daily opioid dosages close to or greater than 100 MME/day are associated with significant risks, that dosages <50 MME/day are safer than dosages of 50–100 MME/day, and that dosages <20 MME/day are safer than dosages of 20–50 MME/day. A specific dosage at which the benefit/risk ratio of opioid therapy decreases could not be identified. Most experts agreed that, in general, increasing dosages to 50 or more MME/day increases overdose risk without necessarily adding benefits for pain control or function and that clinicians should carefully reassess evidence of individual benefits and risks when considering increasing opioid dosages to ≥50 MME/day.
Although there might be situations in which clinicians need to prescribe immediate-release and ER/LA opioids together (e.g., transitioning patients from ER/LA opioids to immediate-release opioids by temporarily using lower dosages of both), in general, avoiding the use of immediate-release opioids in combination with ER/LA opioids is preferable, given potentially increased risk and diminishing returns of such an approach for chronic pain.
Clinicians should calculate the total MME/day for concurrent opioid prescriptions to help assess the patient’s overdose risk. If patients are found to be receiving high total daily dosages of opioids, clinicians should discuss their safety concerns with the patient, consider tapering to a safer dosage.
Clinicians should avoid prescribing opioids and benzodiazepines concurrently whenever possible and should discuss safety concerns with other clinicians who are prescribing controlled substances for their patient.
Nonpharmacologic physical and psychological treatments such as exercise and cognitive behavior therapy (CBT) are approaches that encourage active patient participation in their care plan, address the effects of pain in the patient’s life, and can result in sustained improvements in pain and function without apparent risks. Special emphasis is placed on the use of these approaches to the management of pain.

A Statement regarding “Morphine Equivalency”

The concept of morphine equivalency (ME) is useful only as a tool to provide a possible estimation of relative analgesic potency of one opioid compared to another. It can be a useful tool as applied to an individual when coordinated with feedback based on the individual’s personal experience with the opioids being compared as long as other variables are evaluated as well.

The actual concept of ME is completely flawed when an attempt is made to compare ME from one person to another and potentially even in the same individual at different times. It is completely flawed when attempting to measure any individual’s analgesic needs by some standard of ME.

Furthermore, the measure of ME is not based on any appropriate scientific evidence. The original studies establishing ME between opioids were performed on rats and the conclusions have never, and can never, be meaningfully applied to humans. Therefore, to base opioid prescribing guidelines on a specific ME is simply stupid.

For more information: The Myth of Morphine Equivalency

Comments

The recommendations included in the 2016 CDC Guidelines will likely impact the prescribing patterns of physicians by way of reduced opioid prescribing and reduced opioid dosing in an effort to reduce opioid abuse and overdoses. While the need for increased safety in opioid prescribing is clear, what is also clear is there remains a lack of good research evidence to provide definitive answers as to how best to achieve this. Furthermore, there are no effective alternative medications to take the place of opioids in the management of chronic pain. NSAIDs have limited effectiveness and serious safety concerns of their own. Neuromodulating agents such as the anti-epileptics and anti-depressants have very limited benefits for most pain and have serious tolerability limitations. Opioids remain the most powerful tool in the management of acute and chronic pain, to be used with caution and restraint but not feared or villainized. Unfortunately, the well-intentioned opioid backlash is also likely to impede access to effective pain management.

“The absence of evidence is not evidence of absence”

A Final Statement

“Because pain management is the subject of many initiatives within the disciplines of medicine, ethics and law, we are at an “inflection point” in which unreasonable failure to treat pain is viewed worldwide as poor medicine, unethical practice, and an abrogation of a fundamental human right.”

“The ultimate, effective solution to the opioid problem is education not legislation and regulation.”

– eemd

More Editorial Comments by EE MD:

Comments by others:

Consequences of Regulatory Efforts to Limit Patient Access to Opioids:

Reference Articles

Pain Statistics

Drug Use Statistics

Opioid Use Statistics – Graphs

Nonmedical Use and Misuse of Psychotherapeutic Drugs & Pain Relievers Statistics – Graphs

Addiction to Drugs, Pain Relievers & Heroin Statistics – Graphs

Prescription Opioids – Guidelines for Prescribing Opioids for Chronic Pain

Prescription Opioids – Morphine Equivalence

Prescription Opioids – Overdose

Prescription Opioids – Long-term Use for Chronic Non-cancer Pain

Prescription Opioids – Abuse: Non-medical Use and Misuse of Prescription Opioids

Pain Management – A Human Right

Emphasis on Education

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Accurate Education – Politics of Pain