This paper shows how little evidence is available for the harms and benefits of opioid therapy. However, the universal guidelines for opioid prescibing proposed by the CDC is supposedly evidence-based.
This simply cannot be true. Instead the CDC guidelines are based on opinions (since there is no evidence) of the anti-opioid zealots that are guiding the process.
No study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy evaluated long-term (>1 year) outcomes related to pain, function, or quality of life.
Opioid Abuse, Addiction, and Related Outcomes
No randomized trial evaluated opioid abuse, addiction, or related outcomes with long-term opioid therapy versus placebo or no opioid therapy.
In 10 fair-quality uncontrolled studies (Appendix Table 1) (30–40), estimates of opioid abuse, addiction, and related outcomes varied substantially, even after stratification by setting.
No study reported blinding of outcome assessors to patient characteristics, and some studies also did not assess predefined outcomes in all patients.
Comparative Effectiveness and Harms of Long-Acting Opioids
Three randomized, head-to-head trials of various long-acting opioids found no differences in 1-year outcomes related to pain or function
Two of the trials were rated fair-quality, and one (52) was rated poor-quality.
Methodological limitations included high attrition and open-label design; the poor-quality trial also did not report statistical analyses comparing results between groups for most outcomes. Opioid doses were titrated to effect or were determined during a run-in period, and no trial was designed to assess risk for abuse or addiction.
Risk Assessment Instruments
Four studies evaluated the accuracy of risk assessment instruments, administered before the initiation of opioid therapy, for predicting opioid abuse or misuse. Three studies (2 fair-quality and 1 poor-quality) reported inconsistent results for the 10-item Opioid Risk Tool.
We identified no studies of long-term opioid therapy for chronic pain versus no opioid therapy or nonopioid therapies that evaluated effects on pain, function, or quality of life at 1 year or longer.
Most placebo-controlled, randomized trials were shorter than 6 weeks, and almost all were shorter than 16 weeks
reliable conclusions cannot be drawn from such studies because of the lack of a nonopioid comparison group and heterogeneity of the results
Studies differed in how addiction, abuse, misuse, and dependence were defined and in the methods used to identify these outcomes.
Evidence on the effectiveness of different opioid dosing strategies is limited
Limited evidence indicates no clear differences in effectiveness of different long-acting opioids when patients are permitted to have doses titrated for adequate pain control
However, no randomized trial was designed to assess relative harms, such as overdose, abuse, or addiction.
Evidence on the accuracy and effectiveness of risk assessment instruments for predicting opioid abuse or misuse in patients before initiation of long-term opioid therapy was sparse and was characterized by methodological limitations and inconsistent findings, which precluded reliable conclusions
No study evaluated the effectiveness of risk mitigation strategies, such as the use of urine drug screening, prescription drug monitoring program data, or abuse-deterrent formulations, in reducing harms.
The lack of scientific evidence on effectiveness and harms of long-term opioid therapy for chronic pain is clear and is in striking contrast to its widespread use for this condition and the large increase in prescription opioid–related overdoses
Although it has been asserted that long-term opioid therapy may be more appropriate for certain types of pain problems or for patients assessed as being at lower risk for overdose or misuse, there was insufficient evidence (as detailed in the full report) to determine how benefits and harms vary in patient subgroups defined by demographic, pain, or other clinical characteristics
In summary, reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date
The CDC claims its guidelines are evidence-based, even though such evidence does not exist.
- NIH: The Role of Opioids in the Treatment of Chronic Pain
- Opioids for long-term treatment of noncancer pain