The American Academy of Neurology have published a new position statement in their journal Neurology, asserting that the adverse effects of opioid painkillers outweigh the benefits to patients with chronic, non-cancer conditions such as headache, fibromyalgia and low back pain.
The use of long-term opioid painkillers – such as morphine, codeine, oxycodone or methadone – for chronic, non-cancer pain (CNCP) or pain lasting longer than 3 months was prohibited in most states until the late 1990s.
However, an early case series study suggested that these patients could take opioids safely in the long term.
The American Academy of Neurology (AAN) Ethics, Law, and Humanities Committee concurred with that study, stating “there is consensus among pain specialists that opioid therapy is appropriate for selected patients with CNCP and can provide sustained benefit to such patients.”
Subsequently, pain advocacy groups and pain specialists successfully lobbied policy-makers to lift this prohibition, resulting in liberalized use of opioids for CNCP across more than 20 states by the end of the 20th century.
However, in the new position paper, the AAN now suggest that the modified regulations may have been too permissive, citing as an example a ruling that “No disciplinary action will be taken against a practitioner based solely on the quantity and/or frequency of opioids prescribed.”
The position paper makes the case that the lobbying campaigns occurred in the absence of any clear evidence from clinical trials that opioids are a safe or effective treatment for patients with CNCP.
The author of the position paper, AAN Fellow Dr. Gary M. Franklin, told Medical News Today that “pent-up demand for more effective treatment of chronic pain” drove the lobbying, which placed particular emphasis on a perceived undertreatment of chronic pain.
Also, he said, pain specialists pushing for more permissive use “had reasonable experience with use of opioids for cancer pain and thought their patients with chronic pain could also safely receive opioids. All of that opinion was based on no higher quality evidence.”
More than 100,000 people have died from using prescription opioid painkillers since the late 1990s when liberalization occurred. Dr. Franklin says that the death rate associated with prescription opioids is an epidemic, with more deaths in the most vulnerable groups from opioids than from firearms and car accidents.
Despite no substantial evidence that opioids maintain pain relief over long periods of time, studies show that more than 50% of patients taking opioids for at least 3 months are still taking these drugs more than 5 years later.
With a high risk of overdose, dependence or addiction associated with long-term opioid use, these statistics represent a serious problem. We asked Dr. Franklin if this indicates that doctors are largely naive to the evidence available for opioid painkillers and the risk of addiction associated with them.
“Yes, I believe most prescribers are quite unaware of most of the points made in the paper,” he answered. “That’s one of the reasons I was asked by the Patient Safety Subcommittee of the AAN to write the article.”
The position paper sets out a series of recommendations for doctors to prescribe opioids more safely. In particular, the AAN suggest that doctors should consult with a pain management specialist if dosage exceeds a morphine-equivalent dose of 80-120 mg per day.
The paper also suggests:
- The creation of an opioid treatment agreement
- Screening for current or past drug abuse
- Screening for depression
- Using random urine drug screenings
- That medications such as sedative-hypnotics or benzodiazepines with opioids should not be prescribed
- Assessing pain and function for tolerance and effectiveness
- Tracking daily morphine equivalent dose using an online dosing calculator
- Seeking help if the morphine-equivalent dose reaches 80-120 mg and pain and function have not substantially improved
- Using the state Prescription Drug Monitoring Program to monitor all prescription drugs the patient may be taking.
“These types of recommendations have been part of most published guidelines,” Dr. Franklin admitted to MNT, but he said that most doctors “aren’t doing sufficient screening using brief, publicly available and valid screening tools.”
As well as more research regarding the effectiveness of opioids, Dr. Franklin argues that changes in state and federal laws are needed to ensure patient safety when prescribing these drugs.