Further studies are needed to better support physicians in using opioids to treat patients with chronic pain. That's according to an NIH Pathways to Prevention Workshop final report(annals.org) published online Jan. 13 in Annals of Internal Medicine.
Robert Rich, M.D., who chaired the AAFP opioid and pain management workgroup for the Academy's Commission on Health of the Public and Science, told AAFP News that all aspects of treating pain with opioids require more and better evidence-based research.
"In my clinical practice, I find there are few evidence-based guidelines that adequately address the patient-selection criteria to advise a provider on who and who not to order opioids for when treating chronic pain," he said.
The same goes for determining when to initiate opioid therapy in the spectrum of medications and other treatments for various pain syndromes and responding to patient requests for increases in opioid therapies. The latter requires being able to identify what clinical criteria, if any, help to differentiate legitimate requests for increases from those that are not.
Another study(www.nejm.org) published Jan. 15 in the New England Journal of Medicine (NEJM) reviewed trends in opioid analgesic abuse and mortality in the United States. It found that although opioid prescriptions and abuse skyrocketed from 2002 to 2011, a collective effort to curb the problem nationally seems to have slowed the deadly trend.
- According to a recent report, a dearth of research has left physicians in the lurch when it comes to finding guidance on the best approaches to treating various types of pain.
- Another study published in the New England Journal of Medicine found that although both opioid prescriptions and abuse of the drugs skyrocketed from 2002 to 2011, a comprehensive effort to curb the problem nationally seems to have slowed the deadly trend.
- According to CDC drug overdose mortality data, deaths from painkillers have been stable since 2012, but mortality from heroin use has increased for the third consecutive year, up 39 percent since 2012.
Meanwhile, the CDC's 2013 drug overdose mortality data(www.cdc.gov) showed deaths from opioid painkillers have been stable since 2012, but mortality from heroin has increased for the third consecutive year, up 39 percent since 2012.
According to Rich, it's not all that difficult to draw a line between the two statistics.
"I have seen data from several sources, as well as heard anecdotal reports from ER staff members, noting that as community efforts to limit the use of prescription pain relievers become successful, the use of heroin and related substances of abuse goes up, reflecting the limited availability of prescription opioids," he said.
Recommended Opioid Use Resources
As for managing patients with chronic pain, Rich recommended family physicians start with AAFP resources for opioid prescribing and pain management. This includes the Academy's position paper "Pain Management & Opioid Abuse" and American Family Physician's AFP by Topic Chronic Pain resource.
He also recommended consulting prescribing guidelines most state medical boards promote, as well as the Federation of State Medical Boards' Model Policy on the Use of Opioid Analgesics in the Treatment of Chronic Pain(www.fsmb.org) and Model Policy on DATA 2000 and Treatment of Opioid Addiction in the Medical Office.(www.fsmb.org)
For currently available guidance on particular pain syndromes such as back pain, Rich recommended that health care professionals review guidelines developed by relevant groups such as the American Academy of Pain Medicine, the American Pain Society and even the U.S. Department of Veterans Affairs, which has done extensive work on chronic pain in veterans.
First FDA-approved Abuse-deterrent Hydrocodone Product Released
On Jan. 26, Stamford, Conn.-based Purdue Pharma announced its U.S. launch of Hysingla ER (hydrocodone bitartrate) extended-release tablets CII, which is the first and only hydrocodone product to be recognized by the FDA as having abuse-deterrent properties. The drug is intended to deter misuse and abuse via chewing, snorting and injection, according to a news release.(www.purduepharma.com)
Hysingla ER does not contain acetaminophen, which, when overused, can be a leading cause of acute liver failure.
"Acetaminophen toxicity and the misuse and abuse of opioids are real concerns among clinicians treating people with chronic pain," said Bob Twillman, Ph.D., executive director of the American Academy of Pain Management, in the news release. "The availability of a hydrocodone product with abuse-deterrent properties that does not contain acetaminophen gives health care professionals and chronic pain patients an important new treatment option."
The FDA approved Hysingla ER in November, and the drug is now available in multiple dosage strengths.
Rich said he is aware of several evidence-based initiatives currently underway that aim to update/rewrite guidelines regarding pain management and treatment of various pain syndromes. "As an AAFP representative, I have the opportunity to participate in two of these initiatives and hope that we will be able to answer some of the questions noted in the NIH report and from everyday clinical practice," he said.
Rich highlighted key points from various safe-prescribing guidelines on opioids as a refresher for family physicians:
- Make use of simple tools to screen patients for coexisting substance abuse and behavioral health problems and, if problems are detected, either provide treatment through your practice or refer patients elsewhere for treatment.
- Use pain contracts/treatment agreements with each pain patient and uniformly abide by the tenets of those agreements.
- Make frequent use of the controlled substance reporting systems now in place in most states and intervene when irregularities are found.
- Institute policies for routine drug monitoring (urine or blood), make sure that you understand how to properly interpret the results from those screens, and be prepared to intervene when irregularities are found.
- Be aware of the increased overdose potential of opioids when used in combination with benzodiazepines and/or sleep agents. Also be aware of the increased risk associated with the use of these agents in patients with coexisting health problems such as chronic obstructive pulmonary disease or liver disease.
It's important for family physicians to try to tailor a therapeutic regimen for each patient's type of pain, he said. Medications may include nonsteroidal anti-inflammatory drugs, acetaminophen, antidepressants, anticonvulsants (particularly for neuropathic pain) and judicious use of muscle relaxants.
In particular, because chronic pain is often associated with an element of depression, Rich recommended considering use of antidepressants in these patients. Nonpharmacologic treatment alternatives to opioid prescribing may include physical therapy, chiropractic therapy, acupuncture and/or relaxation therapy.
"Two principles that I emphasize as part of pain management include making sure that each patient gets adequate sleep (including treating sleep apnea if indicated) and persuading each patient to be as physically active as possible (including getting a patient back to their occupation if at all possible)," he said.
Opioid Abuse and Mortality
Rich agreed with the NEJM researchers that some of the plateauing of opioid prescribing and related abuse that occurred from 2011 to 2013 can be attributed to stepped-up enforcement of new and existing regulations that aim to control opioid prescribing activity.
"Likely, this is the effect of the increased educational efforts of multiple organizations focusing on proper prescribing and use of alternative treatments by the provider community," he said. "I also would attribute some of this to decreased demand by patients from the negative publicity associated with opioids, including the many tragic stories in the media of opioid overdose and death."
As for the relationship between the recent slowdown in opioid abuse and the steep increase in heroin use, Rich said if he suspects a patient is using heroin, he points out the dangers of this and other street drugs, highlighting the risk of unknown additives and variable dosages of these drugs, which significantly increase the risk of overdose, organ toxicity and death. "If at all possible, I have tried to persuade these patients to agree to referral to a substance abuse treatment program," he said.
Although there is still work to be done, family physicians have many of the guidelines and tools that will enable them to safely treat patients with legitimate pain issues. For some patients, Rich said, opioids clearly are a necessary component of an overall treatment program. Ongoing research is designed to help physicians properly identify and manage patients whose treatment plan might be more complex.
"There are not enough patient management specialists available to treat every patient with chronic pain," Rich said, "and since, as family docs, we also treat our patients' other health care needs in addition to their chronic pain, the bulk of pain management will be done in our offices."
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