Crucial New Guidance on Opioids and Pain

From the blog of Dr. Nora Volkow, Director, National Institute of Drug Abuse
April 6, 2016

Millions of Americans suffer from opioid use disorders involving prescription pain medications, and each day more than 40 people fatally overdose on them. Although these medications have a legitimate and important role in the treatment of severe acute pain and some severe chronic pain conditions, it is clear that they are also over-prescribed or prescribed without adequate safeguards and monitoring, a situation that has significantly contributed to the alarming rise in opioid use disorders, and to the related resurgence of heroin use we are also seeing in many communities.

Last month, the Centers for Disease Control and Prevention took a major step toward addressing these intertwined crises by issuing new guidelines for prescribers about the use of opioids for treating patients with chronic pain—who according to some studies now account for 70 percent of the opioids dispensed in this country. The CDC recommends that opioids should not be the first line or only treatment for patients who present with chronic non-cancer pain.

It is not simply an issue of safety. Recent reviews of the science have found surprisingly little evidence supporting the effectiveness of opioids in the treatment of chronic pain conditions (defined as pain lasting longer than 3 months). In some cases, opioids may even contribute to a worsening of pain (hyperalgesia), leading to a vicious cycle of taking more opioids to treat a condition that the medication itself has made less tractable.

The new guidelines thus recommend that non-opioid therapies, such as non-steroidal anti-inflammatory drugs (NSAIDs) like aspirin and ibuprofen, as well as non-drug treatments like exercise and cognitive behavioral therapy, should be considered in lieu of or in conjunction with opioid medications. When opioids are prescribed, physicians should prescribe the lowest effective dose, and closely monitor and follow-up with their patients.  Notably, the new guidelines do not apply to treatment of cancer pain or end-of-life care.

Of course, reducing the use of opioids by primary care physicians must be balanced against the efficacy of these drugs for some patients. The aim is not to take these powerful analgesics away from those who need and safely benefit from them, but to ensure they are only used where they are effective, and at the same time reduce the risk of both diversion and the development of substance use disorders.

As in so many other areas, pain is an area where we need more science. The lack of evidence regarding opioids in chronic pain is matched by a lack of evidence for any treatment in these disorders. Other available pain relievers like NSAIDs also have their liabilities and potential safety issues, and their efficacy for treating chronic pain conditions will also require further study. Recognizing the liabilities and limitations of opioids is also an impetus to redouble our efforts to develop new pain treatments that would be safer and more effective than currently available medications. Compounds that modulate signaling in the body’s endocannabinoid system, for example, are an active area of research and may yield new pain pharmacotherapies in coming years.

 

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