Chronic Pain in the Aftermath of the Opioid Backlash

Chronic Pain in the Aftermath of the Opioid Backlash | Complementary and Alternative Medicine | JAMA | The JAMA Network – Kurt Kroenke, MD, – May 11, 2017

 National Institutes of Health (NIH) funding for pain research declined sharply from 2003 to 2007 by an average of 9% per year, and the federal response to a 2011 Institute of Medicine report on pain in the United States has been limited and disproportionally focused on reducing opioid use rather than increasing pain relief.

Analgesic options for patients with chronic pain have steadily declined

What follows in a damning review of the limited efficacy and dangerous side-effects of non-opioid medications.  

Acetaminophen has been found to have minimal efficacy for low back pain and only small benefit for osteoarthritis. 

Similarly, the analgesic effects of nonsteroidal anti-inflammatory drugs (NSAIDs) for low back pain are very small. 

Moreover, the US Food and Drug Administration has strengthened its warning about the cardiovascular risks associated with NSAIDs, noting that there may be some risk even with short-term use among healthy individuals, although the risk appears greater among those with cardiovascular disease, with cardiovascular risk factors, and with longer-term use.

Several classes of drugs, such as gabapentinoids (gabapentin, pregabalin) and serotonin-norepinephrine reuptake inhibitors (duloxetine, milnacipram) are FDA-approved for neuropathic pain and fibromyalgia, but it is unclear if they are effective for the broader group of patients with low back pain, osteoarthritis, and other musculoskeletal pain disorders.

Tricyclic antidepressants and muscle relaxants are often used as adjunctive pain treatments but have a relatively weak evidence base for chronic pain

the movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an overreaction.

First, an estimated 5 million to 8 million people in the United States use opioids for long-term management [of pain].

Second, recent NIH and Centers for Disease Control and Prevention guidelines recognize that judicious prescribing and monitoring of opioids is a viable option for selected patients.

Third, placebo-controlled trials have shown a modest analgesic effect of opioids, whereas the paucity of evidence for long-term effectiveness is true of pain treatments in general

Fourth, many patients respond better to one analgesic than another, just as patients with other medical conditions have differential medication responses.

Given the small analgesic effect on average of most pain drugs, the few classes of analgesic options, and the frequent need for combination therapy, eliminating any class of analgesics from the current menu is undesirable

Excessive use of phrases like opioid epidemic should be avoided (a literature search revealed more than 100 articles with the words opioid and epidemic in the title). An epidemic generally suggests a disease that is widespread and usually highly contagious rather than limited to a minority of those exposed.

Analysis of a large national pharmacy database found that among more than 10 million incident opioid recipients, the probability of transitioning to long-term opioids was only

  • 1.3% by 1.5 years after the first prescription,
  • 2.1% by 3 years,
  • 3.7% by 6 years, and
  • 5.3% by 9 years

Thus, only a small fraction of patients prescribed opioids progress to long-term use.

The reality, however, is that most patients receiving an initial opioid prescription do not proceed to chronic use and among the subset that do use long-term opioids, the majority neither misuse nor experience an overdose.

An unintended consequence of excessive concerns raised about opioids could be an increasing reluctance among clinicians to prescribe even small amounts of opioids for a limited time for acute pain, including for

  • patients discharged from the emergency department,
  • those who are recuperating from surgical procedures, or
  • persons with severe dental pain.

No clinician wants to be accused of contributing to the opioid “epidemic.” Meanwhile, some patients may be embarrassed about asking for effective pain relief.

Nonpharmacological pain therapies provide a promising alternative. Cognitive behavioral therapy (CBT) has the strongest evidence. Pain self-management programs and regular exercise are also beneficial. 

Emerging, although less conclusive, evidence exists for yoga, mindfulness or meditation-based therapies, acupuncture, chiropractic, and massag

However, these therapies are neither a panacea nor a universal replacement for analgesics

First, there is a paucity of head-to-head trials of analgesic vs nonpharmacological therapies

Second, placebo controls can only be fully masked in drug trials, making it more difficult to distinguish the specific vs nonspecific effects of nonpharmacological therapies

Third, evidence of long-term effectiveness is weak for nonpharmacological and analgesic treatments alike

Fourth, CBT, exercise, and other behavioral treatments require sustained practice and lifestyle changes, reducing their effectiveness in many individuals unable to sustain such activities over many years

Fifth, there is an inadequate workforce trained in pain-focused CBT, and reimbursement strategies often favor non–evidence-based procedural or surgical pain treatments.

Whereas skeptics tend to focus on the rather modest separation from placebo of all treatments for chronic pain, placebo effects should not be entirely dismissed.

Pain responses to placebo range from 30% to 50% and have a biological underpinning: Effective placebo manipulations trigger the release of endogenous opioid peptides that act on the same receptors as synthetic opioid drugs such as morphine

Imperfect treatments do not justify therapeutic nihilism.

A broad menu of partially effective treatment options maximizes the chances of achieving at least partial amelioration of chronic pain.

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