This chapter focuses on the use of opioids for care of chronic musculoskeletal pain conditions such as back pain, and addresses clinical and public health issues that arise when opioids are used long-term for these conditions.
For our purposes, long-term use is defined by use of opioids for two months or more on a daily or near-daily basis. While the large majority of patients who use opioids for a few days or weeks discontinue use, the likelihood of sustained use is increased among persons who sustain daily or near daily use for more than two months
That’s because “daily use” is due to daily pain!
Many patients using opioids long-term manifest “complex chronic pain”, characterized by:
- Absence of readily identifiable causes, a definitive differential diagnosis and/or highly effective treatments;
- presence of activity limitations and disabilities, patient concerns that pain cannot be controlled, may not improve, and that underlying causes of pain make it unsafe to resume normal activities;
- Presence of diffuse pain and/or clinically significant depression and anxiety.
I’m disgusted that they pair “diffuse pain” with depression and anxiety. There’s no scientific basis for doing so, it’s just a belief of the researchers that’s deeply embedded in the very design and purpose this study and a clear example of research bias.
While the pain status of chronic pain patients using opioids long-term is highly variable, many chronic pain patients using opioids long-term have some or many of these features of complex chronic pain
Chronic pain conditions for which opioids are most often prescribed include
- back and neck pain,
- osteoarthritis and extremity pains,
- shoulder pain,
- orofacial pain,
- pelvic pain, and
- fibromyalgia or
- chronic widespread pain.
Although these recommended practices are prudent, no well-controlled research has determined whether enhanced COT monitoring reduces risks of opioid abuse, overdose or other potential adverse outcomes
A review concluded that treatment of chronic pain “may be further complicated when patients and health care providers have differing goals and attitudes concerning treatment. Difficulties in collaborative treatment decision making may result.”
Why opioid dose matters
Clinical guidelines have always urged care in prescribing opioids, but there has not been agreement of guidance regarding COT dose.
And that is exactly how it should be (this was from 2014); how can there be guidance for something so variable?
It’s just as stupid as saying that because many Americans are 40lbs overweight, all Americans must lose 40lbs, regardless of their gender or physical condition.
- Some experts recommend a low-to-moderate dose ceiling,
- while others advocate increasing a patient’s opioid dose until pain is controlled, with no dose ceiling.
However, we do not know if these two distinctly different COT dosing strategies result in long-term differences in pain outcomes for patients, and we lack evidence from long-term controlled trials regarding differences in COT effectiveness and safety by dose
Whenever they are being unreasonable about limiting opioids, they use the “lack of evidence” as their evidence that opioids are not effective.
Patient risk factors
Chou et al’s structured review of opioid misuse prediction concluded that, “only limited evidence exists to determine optimal methods for prediction and identification of aberrant drug-related behaviors”, a conclusion also supported by Turk et al.’s review.
Citing methodological shortcomings of existing studies, Chou’s review noted, “…because the methods used to define aberrant drug-related behaviors did not distinguish relatively less serious from more serious behaviors…the clinical importance of their identification is unclear”.
Only one study has predicted risks of prescription opioid abuse among COT patients based on patient variables and duration of opioid use. Hojsted et al. found 82% sensitivity but only 58% specificity in predicting prescription opioid addiction.
Drug regimen risk factors
Expert guidelines assert that around the clock dosing, with long-acting opioids, reduces risks of addiction by providing more stable opioid blood levels, improved pain control, and reduced reinforcement of problematic drug use behaviors.
This only works as expected if pain severity (and pain perception) is constant.
However, evidence on whether time-scheduled dosing improves pain control and reduces addiction risks is limited.
COT patients using time-scheduled dosing, compared to those using pain-contingent dosing, received substantially higher average daily doses and were much more likely to report concerns about ability to control use of opioid analgesics, while pain control and satisfaction with opioid analgesics did not differ.
Data questioning COT Effectiveness
Observational studies have found that patients using opioids, and those on higher dose regimens, have poorer functional status and lower quality of life than patients not using opioids or patients on low-dose regimens.
I’m appalled that all these articles are written as though taking opioids were a completely independent variable/activity instead of tied directly to the amount of pain a person is dealing with. People who need high doses probably have high pain levels, and that’s what lowers their quality of life, not the medication they take to ameliorate it.
People who need high doses of any drug will be much sicker than those that don’t need them, but to blame it on the drugs they are taking to treat their health problem is absurd.
Cohort studies of worker’s compensation patients found that those using opioids are delayed in returning to work relative to patients not using opioids and patients receiving higher opioid dose are also delayed returning to work relative to patients on lower opioid doses.
This is perfectly logical when you remember that higher and more consistent opioid dosing occurs in response to the patient’s pain level.
In assessing COT risks, there is a need for controlled research that assesses the full spectrum of health risks of opioids, relative to benefits. There is also a need for research that evaluates the comparative safety of opioids relative to other analgesics are commonly used for management of chronic musculoskeletal pain, such as non-steroidal anti-inflammatory drugs (NSAIDs) and acetaminophen.
Accumulating evidence regarding NSAID risks resulted in the American Geriatrics Society to preferentially recommend opioids over NSAIDs for management of chronic pain, but this recommendation was not based on a direct comparison of the comparative safety of opioids relatively to NSAIDs.
This is an entirely sensible policy and it’s also the reason my doctor started me on opioids in 1995.
We had tried several treatments, therapies, and even surgeries to alleviate my ever-increasing pain and it would have taken consistent and huge amounts of NSAIDs and Tylenol to ease it, so he prescribed the much less harmful opioids instead. Opioids are only dangerous if you are prone to addiction, and since I’m not, they are very safe for me.
Given uncertainty about the long-term effectiveness of COT, and growing evidence that potential risks and harms are greater than initially believed, use of opioids for long-term management of chronic pain should be considered with caution commensurate with the potential risks.
I don’t disagree that opioids should be used cautiously, but this certainly doesn’t mean to not use them at all.
Practice points for selective and cautious opioid prescribing among patients with chronic musculoskeletal pain conditions
- Put patient safety first – Find common ground with patients by emphasizing their safety
When a patient is left in unrelieved pain, there’s a different risk that’s left unmentioned: death by suicide.
- Do not sustain opioid use long-term without decisive benefits – Initial evaluation of long-term opioid use should be based on a therapeutic trial lasting no more than 90 days, preferably less. Long term use of opioids should only be continued if decisive benefits are observed during the trial. Opioids should not be continued if improved function is not sustained. Involve the patient in determining functional goals for therapy. Continually monitor the benefit-to-harm ratio as benefits may decrease while harms accrue over time.
This seems completely obvious and the same criteria apply to *all* pharmaceutical use, not just opioids. Why should opioids be prescribed if there’s no gain for the patient?
The real issue is WHO gets to decide whether the patient is “improved”.
- Think twice before prescribing long-term opioids for axial low back pain, headache and fibromyalgia
Thinking twice is different than not thinking at all and simply obeying inflexible “guidelines”.
All patients are individuals and should be treated as such, so each patient’s specific situation and response to opioid medication must be evaluated.
This is exactly what doctors are for and why we don’t “practice medicine” by algorithm – at least not yet, but it’s coming.
- Consider intermittent opioid use – Continuous use of long acting opioids has not been proven more effective or safer than intermittent use of short-acting opioids. Time-scheduled opioid prescribing has not been proven to reduce risks of opioid misuse or addiction.
This is true not just for opioids. Dosing of any medication should be according to the symptomatic benefits. While there are few symptoms, no medication is needed, and then when symptoms do appear, medication *is* needed.
I’m lucky that my pain isn’t consistent and becomes severe only if I’m active. We’re supposed to be active and even exercise, aren’t we? If we don’t, we’re told our pain is *because* we don’t exercise enough.
Without opioids, I’d be incredibly handicapped and unable to do much more than lying around, which would then lead to deconditioning and a whole slew of different pains.
That’s not the life I want – and it may not even be tolerable for my hyperactive mind to lie around passively, all day every day, to avoid pulling on my connective tissue and causing myself pain.
- Systematically evaluate risks
Indeed, because the risk of under-dosing means a patient will not be as active as possible, they will suffer from deconditioning and become more disabled over time.
- Keep opioid doses as low as possible – Reaching doses of 50 to 100 milligrams morphine equivalents or higher should trigger re-evaluation of the therapy.
Again, this is an obvious “rule” that applies to all drugs.
Opioid-related risks appear to increase with dose.
When the best they can say is that risks “appear” to increase, it’s an admission that it’s never been proven.
Given the lack of adequate trials data, recent epidemiologic studies suggest the need for caution when considering long-term use of opioids to manage chronic musculoskeletal pain, particularly at higher dosage levels.
A “need for caution” is NOT a prohibition and should equally be applied to any other medications or treatments for any other syndromes or diseases.
Are they suggesting that it’s normal medical practice to prescribe medications “without caution”?
No drugs should ever be prescribed carelessly.