Opioids: use and misuse in chronic pain management

Opioids use and misuse
December 2, 2020

Opioids have been historically used for pain for thousands of years, but opioid therapy for chronic non-cancer pain remains controversial, despite the fact that opioids are one of the most commonly prescribed medications in the United States.  The prevalence of chronic pain in the adult population averages a median point prevalence rate of 15%, but some studies suggest rates of nearly 40%.  Prevalence rates are higher in the elderly, those suffering significant physically traumatic injuries, or malignancy.  Pain is often associated with severe functional limitations and difficulty in performing daily life activities.  Pain disables more people than heart disease and cancer combined, carrying a significant societal cost.

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Although pain is difficult to measure directly in individual patients, as it is considered a “subjective” symptom, its effects are abundantly clear in the suffering individual and their immediate caregivers, reducing individual and caregiver socioeconomic status. Reduced earnings are evident in not only the individual with pain, but their immediate associated caregivers by at least one quartile, which is reversed upon adequate relief of pain and return to function of the individual.

Judicious use of opioids in selected patients with chronic non-cancer pain who have not responded to other treatments and analgesic medications is considered acceptable, but remains controversial due to concerns regarding the long-term effectiveness, safety, risk of tolerance, dependence, and abuse.  Keep in mind that the efficacy of opioids for chronic non-cancer pain has been demonstrated in only short-term trials, including those for neuropathic pain, but the evidence is limited for long term chronic non-cancer pain.

Regulatory concerns by prescribers are neither inconsequential nor unfounded, due to the unprecedented diversion rates by unscrupulous “patients,” with up to 30% of patients diverting some or all of their medication for direct economic gain or for recreational abuse.  Simultaneously, empowered patients rightfully demand relief from suffering while regulatory bodies rightfully attempt to limit improper prescribing as a significant public health and policy concern.  Sophisticated illegitimate patients also leverage physician prescribing by threatening regulatory reporting for under prescribing or by fabricating physician quality of care concerns.

Legitimate prescribers often feel caught between the needs of patient’s presenting with subjective complaints, and their fear of improper prescribing to unscrupulous sophisticated “patients.”

Further muddying the waters, some individuals truly legitimate in their need for opioid analgesia, undergo neuroplastic changes in the peripheral and central nervous system (CNS) leading to a sensitization of pronociceptive pathways, resulting in an opioid-induced hyperalgesia (OIH).  This condition is characterized by a paradoxical response, whereby a patient receiving opioids for the treatment of pain could actually become more sensitive to stimuli, resulting in a reduction in the opioid’s treatment effect in the absence of disease progression, often mimicking the neurobehavioral effects of addiction.  Escalating doses in chronic opioid therapy might cause OIH by inducing a vicious cycle of increasing dosage and anxiety for both the physician and patient.  Referral to a qualified interventional pain clinic for multimodal therapy to minimize opioid utilization is strongly encouraged for patient’s with suspected OIH, reducing both physician anxiety and improving patient care.

Safely navigating a course of care in these treacherous waters poses a difficult challenge to the prescriber, sworn to relieve suffering of the individual but cognizant of the unintended consequences to society and to self for inadvertent improper prescribing.

Although many of these challenging patients can be managed in a primary setting, the need for close monitoring for therapeutic use, overuse, abuse, and diversion of controlled substances is an absolute necessity and requires specific unwavering treatment protocols, which will result in occasional patient dissatisfaction, sometimes quite vocal. These protocols must include a methodology to monitor consumption against prescription dispensation, with an accurate cost effective biological validation, such as a qualitative in-office urine drug screen cross validated by a more sensitive quantitative laboratory analysis.  These protocols must also minimize the use of opioids overall, using adjuvant therapies which should include interventional, behavioral, non-opioid pharmaceutical, or physical therapy options.

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Most importantly, a clearly defined prescriber exit strategy should exist when utilizing opioids to treat chronic pain because of the potential complications in managing these patients such as opioid dependence, addiction, and abuse.