Opioids for chronic noncancer pain

Abstract

The Patient Safety Subcommittee requested a review of the science and policy issues regarding the rapidly emerging public health epidemic of prescription opioid-related morbidity and mortality in the United States. Over 100,000 persons have died, directly or indirectly, from prescribed opioids in the United States since policies changed in the late 1990s. In the highest-risk group (age 35-54 years), these deaths have exceeded mortality from both firearms and motor vehicle accidents. Whereas there is evidence for significant short-term pain relief, there is no substantial evidence for maintenance of pain relief or improved function over long periods of time without incurring serious risk of overdose, dependence, or addiction. The objectives of the article are to review the following: (1) the key initiating causes of the epidemic; (2) the evidence for safety and effectiveness of opioids for chronic pain; (3) federal and state policy responses; and (4) recommendations for neurologists in practice to increase use of best practices/universal precautions most likely to improve effective and safe use of opioids and to reduce the likelihood of severe adverse and overdose events.

Rethinking chronic pain in a primary care setting

“…Similarly, most opioids can provide limited relief for some patients with trauma, inflammation, and neuropathic pain, but accumulating data suggest that they are not beneficial in patients with fibromyalgia (FM) and similar conditions (see below). [27,28] Thus, understanding the likely causes and, more importantly, the basic pathophysiology of chronic pain as much as possible can help guide the selection of appropriate therapy for each patient.…”

“…Due to the unique risks, however, greater caution must be exercised when considering initiating opioid therapy or prescribing it as part of an ongoing medication regimen. [14,27,91,92] Recent treatment guidelines, pain medicine thought leaders, the National Pain Strategy, the FDA, and the CDC agree that opioids may be medically appropriate and safe for acute pain and for selected patients with chronic pain when such pain cannot be adequately managed with other methods. In fact, the FDA has recently updated the indication for extended release (ER) opioids to read: '.…”

“…[105,106] Similarly, greater caution is called for when considering opioids for the treatment of mixed pain conditions where the contribution of sensory hypersensitivity may be significant, such as patients with CLBP or headache disorder. [27] In this subset of patients, opioid initiation or continuation should be avoided.…”

The Use of Methadone in Refractory Headache Pain in an Opiate Naive Patient with Non Metastatic Burkitt’s Lymphoma and HIV - A Case Report

“…Patient's undergoing inpatient chemotherapy frequently experience headaches throughout their hospital course, most of which remain uncomplicated and treated with oral acetaminophen [8]. Frequently, headache pain is masked by more severe and chronic systemic pain from other medical conditions not limited to cancer patients.…”

Capsule Commentary on Gaither et al., the Association Between Receipt of Guideline-Concordant Long-Term Opioid Therapy and All-Cause Mortality

“…For many non-specific pain disorders, such as low back pain, headaches, and fibromyalgia, the evidence that chronic opioid use is effective long term is non-existent. 3 This makes the use of alternatives all that more attractive, considering that the evidence for dose-related serious harm is much stronger than the evidence of longer-term effectiveness. 4 Larger, more potentially integrated health systems such as the Veteran's Administration may have greater capacity to more adequately deliver multimodal care.…”