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Chronic Pain Therapy: Then and Now

Treating Chronic Pain-Where We Have Been and Where We Are Going

Agency for Healthcare Research and Quality (AHRQ) National Guideline Clearinghouse  July 3, 2017

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In a recent expert commentary featured on the AHRQ weekly newsletter and website, authors L.G. Davis, MD, Sanjog Pangarkar, MD, and Neil M. Paige, MD, MSHS discuss the progression of long-term opioid therapy (LOT) in America and its current trajectory.

Back in the 1990s and 2000s marks the timeframe when prescriptions for opioids in the treatment of non-cancer pain increased like never seen before in the U.S., and LOT became synonymous with the management of chronic pain. As a result, according to a 2015 report from the International Narcotics Control Board, 70% of the world’s opioid use is in the United States but less than 5% of the world’s population, which leads to the speculation that opioids are “an American issue.” Between 1999 and 2011, overdoses and other adverse opioid-related cases nearly quadrupled, and a staggering amount of deaths were attributed to controlled prescription medications annually since 2002, outpacing the number of deaths caused by illicit drugs like cocaine and heroin.

The previous stigma of using prescription opioids seemed to gradually fade as groups advocated for improvements in patient care and quality of life by reducing chronic pain. The Department of Veterans’ Affairs implemented a “Pain as the 5th vital sign toolkit” with a scoring system on a 0 to 10 scale, and any patient with a pain score of 4 or above would require “comprehensive pain assessment and prompt intervention.” Congress soon after declared 2001-2010 the “decade of pain control and research.” Even the U.S. Food and Drug Administration lowered restrictions to allow prescription drugs to be advertised directly to consumers. This catalyzed an increase in marketing that eventually led to more and more non-cancer pain patients being prescribed opioids. In addition to this exposure, insurance companies at the time tended to favor opioids over interdisciplinary pain treatment, which may have led to the noticeable decrease in those programs during this time.

There is a lack of strong evidence to substantiate any benefit of opioid therapy in the long term. According to the article, research done by Dr. Roger Chou and team uncovered no studies of opioid treatment vs. placebo, nor of any study comparing LOT greater than 1 year to non-opioid treatment that produced any assessment of outcomes related to pain, function or quality of life. Furthermore, Dr. Chou’s studies indicate increased risk of overdose, opioid abuse, and risk of myocardial infarction associated with opioid therapy for chronic pain. The VA also did a small study with marginal results, further casting a shadow of doubt about the effectiveness of LOT.

Approximately 5 years ago, the Opioid Safety Initiative (OSI) Task Force was chartered as a result of the increasing concern over public safety, and the effort was launched a year later to reduce risk, improve safety and treat substance use disorders (SUDS). This effort included recommendations to implement “opioid risk assessment tools, informed consent for opioid prescribing, toxicology screening, and periodic review of prescription drug monitoring program (PDMP) databases; as well as “distribution of naloxone rescue kits for patients on high dose or high risk LOT; decreasing maximal morphine equivalents (ME); and avoiding the combination of opioids and benzodiazepines.” Clinical reminders were established by the VA to reinforce compliance of the mandate, and in some VA locations patients above a set morphine equivalents (ME) threshold would require mandatory case reviews. Over the 3 year period, the OSI saw an overall improvement in the noticeable decreases in number of patients prescribed opioids overall, in patients receiving opioids greater than 100mg ME, and in patients combining opioids with benzodiazepines.

The VA guidelines provide a framework for promoting the importance of education and communication for and between providers and patients to develop non-opioid strategies for chronic pain therapy, with the ultimate goal being to reduce LOT as much as possible. “The key to success for long-term chronic pain management is a comprehensive team approach. This is where full multidisciplinary engagement is necessary to ensure effective and efficient monitoring as we work to ensure the safety, appropriateness, and success of all treatments. Both provider and patient must understand the risks involved with LOT. Patients must be empowered to embrace self-management and to understand the many options to treat chronic pain, other than LOT. When there are no other options but LOT, patients must be educated why the provider needs to follow established guidelines for safety monitoring.”

Disclaimer: The views and opinions expressed in the article are those of the authors and do not necessarily state or reflect those of Dawn Cook Consulting LLC or its individuals.