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For the first time, health care providers have evidence-based clinical practice guidelines to aid in the prescribing of opioid analgesics for those patients suffering from chronic noncancer pain. These guidelines were recently published, the result of a collaborative effort between the American Pain Society (APS) and the American Academy of Pain Medicine (AAPM). A panel of pain management experts from these two groups came to the conclusion that opioid pain medications are safe and effective for certain well-monitored patients.
The APS and the AAPM reviewed thousands of publications, and based on the clinical evidence, recommendations were made for clinicians who care for adults with chronic noncancer pain. Such conditions for which opioids are used include chronic low back pain, accident trauma, arthritis, fibromyalgia and sickle cell disease.
Obviously, the guidelines advise clinicians to attempt to treat the pain with other alternatives before chronic opioid therapy is chosen. Just as obviously, clinicians are reminded to know the medical history of their patients thoroughly, assessing all the while the risks of substance abuse, misuse or outright addiction. And so the guidelines suggest the patient be given guidelines: for example, patients should agree to fill prescriptions at one pharmacy only, and they must agree to drug testing.
Patients should be monitored regularly for pain intensity, functional level, and compliance with recommended use of medications. Such monitoring is important, as other illnesses, psychological or physical, can impact the experience of pain. Alas, monitoring also includes pill counts, urine drug screens, and prescription monitoring.
Perhaps such monitoring will indirectly encourage physicians to use opioids in those cases where they truly are indicated; it is not unusual for physicians to withhold opioids for fear of the legal ramifications.
Interestingly, evidence of outcomes of patients with low back pain or headache who are treated with chronic opioids often have a worse outcome over the long term. In fact, opioid use may in itself be a risk factor for worsening or progression of chronic noncancer pain conditions.
Clearly, we are failing in obviating pain when we must depend on chronic pain medications. Research must continue to develop pharmacologic and pyschologic tools which will allow for the minimum use of opioids. There are more than a few experts in chronic pain who feel that prescribers of opioids are creating an addiction and not a cure for those with chronic pain. But while the answer for some with chronic pain lies in biofeedback or anti-depressant medications or acupuncture, to name a few pain-relieving modalities, the answer is certainly not universal.
