M. E. Lynch &J. Katz
Published online: 04 May 2017
Information courtesy of Kev James, Chronic Pain Patient Advocate. LinkedIn
This study pulls no punches:
“The use of opioids in chronic non-cancer pain continues to be a flashpoint in medicine. The media and others continue to cite rising deaths due to opioids without clarifying that a large percentage of the current deaths are related to illicit highly potent fentanyl and other synthetic opioids coming across our borders from China. This misunderstanding is leading to an increasingly harsh regulatory climate for physicians and many physicians are electing to avoid opioid prescribing completely. Further, in this environment of fear, there are many instances of physicians refusing to treat people with chronic pain. This is unethical and unacceptable, but one can begin to understand given the inappropriate reactions of regulators across the country.”
This was the US experience after the release of the disastrous 2016 CDC Opioid prescribing guidelines, which led to force-tapering of millions of chronic non-cancer pain patients off their opioid pain medication. Patients were forced into lives of intractable pain and the suicide rate in the chronic pain community rocketed. Now, in 2022, the CDC is revising those guidelines, having acknowledged their mistakes in a 2019 press release.
In Australia, the regulations around opioid prescribing were tightened with the same results, many chronic non-cancer pain patients were (and are still) forced-tapered of their opioid pain-relieving medications. This study is one of many that shows opioids are safe and effective where all other therapies have failed, and that chronic non-cancer pain patients experience reduced pain and improved quality of life. Serious adverse events, such as addiction and overdose are rare.
The study refers to the CDCs 2016 guidelines:
The standard supported the controversial maximum dose guidelines published by the US Center for Disease Control (CDC) by stating that doses greater than 50 morphine milligram equivalents (MME) per day warrant careful reassessment and documentation and that doses greater than 90 MME per day warrant substantive evidence of exceptional need and benefit as well as advising against long term opioids in individuals with certain types of pain including headache, fibromyalgia, and axial low back pain. The guideline section of this document also recommended against use in people with mental health issues or psychiatric disorder and young people. One must use care in these populations but to recommend against opioids for whole diagnostic categories is not evidence-based and is discriminatory. It is also non-pharmacological to recommend the same dose for all people regardless of body mass or age
Several key points are important to consider:
A significant subpopulation of people with chronic pain benefit from opioids with a reduction in pain and their access should be preserved
Contrary to the oft-repeated view that there is no evidence that opioids are effective for chronic pain, there is quite a lot of evidence actually.
The National Neuropathic Pain Database group identified that 17.9% of patients with neuropathic pain experienced more than a 30% reduction in pain with a concomitant reduction in pain-related interference, taking a mean daily dose of 81.7 mg oral morphine equivalents
Watson et al. found opioids to be safe and effective in a survey of 84 selected patients with intractable non-cancer pain taking a median dose of 220 mg oral morphine equivalents per day for the whole group and 510 mg per day for the largest group of people with back and neuropathic leg pain.
A Cochrane database review of long-term opioid management for chronic non-cancer pain identified 26 studies involving 4,893 patients and examined 3 routes of delivery (per os, transdermal, and intrathecal).7 All studies demonstrated efficacy and addiction indicators were present in only 0.27%.
A qualitative study examining the lived experience of adults using prescription opioids to manage chronic pain found benefits outweighed the negative effects and that most of the negative effects were socio-culturally induced including participants describing guilt and stigmatization for using opioids
Appropriate and responsible medical exposure to opioids for chronic pain does not lead to addiction
Recent evidence has demonstrated a very low risk of persistent opioid use after medical exposure to opioids following major elective surgery. Of 39,140 opioid-naïve patients who had undergone surgery in Ontario, only 168 (0.4%) continued to receive an opioid prescription one year later.
Notably, the patients at highest risk of continued opioid use had undergone thoracic surgical procedures which are notorious for their high incidence of chronic postsurgical pain (i.e., these patients were most likely taking the opioids to relieve pain). Moreover, it is unclear from these data what percentage, if any, of the 0.4% who were talking opioids at the one-year mark were actually addicted.
Another recent study was so compelling that the American College of Surgeons made a public statement online in a press release stating that “opiate pain killers prescribed after severe injury do not lead to long term use,” citing a study on 7,302 patients who had sustained major traumatic injuries. Forty-nine percent filled at least one prescription for an opioid after hospital discharge and only 0.9% were still taking an opioid one year later. Although pain severity was not reported, one sequela of traumatic injury is chronic pain,14 so it is possible that those who were taking opioids were doing so to relieve ongoing pain. As with the above study,11 the authors do not report this as an addiction rate but have indicated this is the rate of individuals who were still taking an opioid one year after hospital discharge12 and given that the rates of persistent postsurgical pain range from 6-68%15 it is probable that most of these patients were using the opioid for pain and not because of an addiction.
The study continues:
We are not arguing that medical exposure to opioids never results in addiction but that the incidence is very low and when prescribed with appropriate precautions it is extremely rare.
Stopping appropriate medical prescribing of opioids will not stop people with addiction from abusing opioids and will cause significant collateral damage to people with pain
Curbing appropriate medical use of opioids has already been demonstrated to harm people with pain.
“…in the United States and Canada, the general use of opioids has decreased to a significant degree such that those of us on the front lines of pain management are finding that patients are experiencing difficulty accessing opioids when they are medically appropriate. In addition, the negative attention to “pain killers” has further stigmatized and harmed people suffering with pain. The pendulum has swung too far and it is critical to bring a balanced perspective to this complex issue so that effective solutions can be put into place and the collateral damage to people with pain can be stopped. “
Another study that explicitly states the pendulum has swung too far:
“While estimates of opioid misuse, abuse, and addiction vary in patients with chronic pain, they clearly represent only a small portion of this unfortunate population.16,17 Why should patients with chronic pain who are prescribed necessary opioids for legitimate medical purposes endure the wrath of policy changes and resultant untreated pain due to criminality of others, or because clinicians are undertrained in identifying risks and addressing those risks? These questions certainly raise ethical concerns.”
“In conclusion, long-term opioids are safe and effective in the management of chronic pain when used appropriately in a significant subgroup of people. Medical use of opioids is not what causes addiction. Curbing appropriate medical use will not solve the problem of illicit opioid use or opioid-related harms. In fact, the evidence supports that the current harsh regulatory climate on prescribers is doing harm to people with chronic pain. The solution is to provide enhanced timely care to those struggling with addiction and substance use disorders and better access to interdisciplinary care for people with chronic pain conditions.”
I rest my case.