Opioid Guidelines Versus Chronic Pain

We overdose, and we slow up the emergency department. We overdose, and we take up in hospital beds. We overdose, and we die.

We are a country that has moved from frowning upon the treatment of chronic pain with chronic opioids, to one that experiences an annual increase in the number of doses of opioids prescribed. This is despite the existence of more than one guideline that claims to guide prescribers towards a safer approach to the management of chronic pain.

However, the annual increase in deaths associated with prescription drug use certainly causes pause, and the turn of a critical eye to what is missing in these guidelines. The latest incarnation of that critical eye can be found in the current issue of the Annals of Internal Medicine, where researchers published their conclusions after a systematic search for and evaluation of the quality of guidelines addressing the use of opioids for chronic pain.

The authors evaluated the quality of 13 guidelines dealing with the use of opioids to treat chronic pain, comparing the respective recommendations regarding lowering risks for overdose and misuse. Two of these guidelines received “high” ratings, both of which applied to a broad range of adults, were developed on a foundation of thorough systematic reviews, and were accompanied by recommendations based on evidence. Seven other guidelines were found to be of intermediate quality; the remaining four guidelines were considered not useful.

Unfortunately, overdoses occur at the lower dosage ranges, and thus there is always someone or some group suggesting that opioids should not be used for chronic pain. Nevertheless, previous reviews of randomized controlled trials conclude that oral opioids are more effective than placebo or anti-inflammatory agents, rendering not only decreases in pain severity as high as 50 percent compared to baseline, but also resulting in significant improvements in functional status. However, the rap against the conclusions of such studies has been that the study quality is not robust, and long-term follow-up of subjects has been absent. Other research has found that abuse occurs in up to almost 4 percent of chronic opioid users, and addiction in as few as 0.04 percent; but almost 12 percent of chronic pain patients on opioids engage in aberrant drug-related behavior, or illegal use of prescription opioids. All of these observations have been incorporated into the better guidelines.

So it is not surprising that the better guidelines provide a sense of support for the prescriber of chronic opioids, while simultaneously emphasizing a careful approach to the chronic pain patient.

The rigorous clinical practice guidelines have the potential to help the health care provider to lower the rates of opioid misuse and overdose in the chronic pain population. While more evidence needs to become available, the more recent and robust guidelines do make similar and clear recommendations about strategies for reducing the risks of chronic opioid use: There now appears to be a consensus on the utilization of thresholds on upper dosing; certain medications are being singled out as potentially more problematic; drug-drug and drug-disease interactions are being clearly outlined; and risk assessment tools are being utilized.

It will be left to future research to determine how opioid risk mitigation strategies impact pain control and opioid abuse patterns.