PHARMACIST STEVE

https://www.iasp-pain.org/Advocacy/OpioidPositionStatement

Opioids are indispensable for the treatment of severe short-lived pain during acute painful events and at the end of life (e.g., pain associated with cancer). Currently, no other oral medication offers immediate and effective relief of severe pain. Although opioids can be highly addictive, opioid addiction rarely emerges when opioids are used for short-term treatment of pain, except among a few highly susceptible individuals. For these reasons, IASP supports the use and availability of opioids at all ages for the relief of severe pain during short-lived painful events and at the end of life. IASP’s 2010 Declaration of Montreal states that access to pain management is a fundamental human right. In some cases, there is no substitute for opioids in achieving satisfactory pain relief.

Despite this stated value of opioids, the role of opioids in the treatment of chronic pain has come into question. Recent open-ended and indiscriminate long-term prescribing of opioids in the United States and Canada has led to high rates of prescription opioid abuse, unacceptable death rates, and an enormous burden to the affected societies. This burden has been a consequence largely of opioid prescribing for the treatment of chronic pain, where long-term effectiveness is uncertain and where harms, especially for high doses, are clear and strongly supported by cautionary data from the affected countries. Such harms include, but are not limited to, addiction and death. Increased prescribing for chronic pain is occurring in some other developed nations, while the developing world continues to struggle with lack of opioid availability for appropriate indications.

IASP strongly advocates for access to opioids for the humane treatment of severe short-lived pain, using reasonable precautions to avoid misuse, diversion, and other adverse outcomes. At the same time, IASP recommends caution when prescribing opioids for chronic pain. There may be a role for medium-term, low-dose opioid therapy in carefully selected patients with chronic pain who can be managed in a monitored setting. However, with continuous longer-term use, tolerance, dependence, and other neuroadaptations compromise both efficacy and safety. Chronic pain treatment strategies that focus on improving the quality of life, especially those integrating behavioral and physical treatments, are preferred. IASP also strongly advocates for continued research to identify ways to minimize opioid risk and find effective alternatives to opioids for the treatment of various pain problems.

Notes

1. This statement is based on best available evidence and expert opinion. See References below.
2. IASP recommends adherence to and promotion of local opioid prescribing guidelines, with special attention to assessing the supportive evidence with appropriate scientific rigor.
3. IASP recognizes the importance of comprehensive educational efforts to teach safe and appropriate opioid use.

References

1. Contextual evidence review for the CDC guideline for prescribing opioids for chronic pain – United States, 2016. CDC Stacks, Public Health Publications, March 18, 2016.
2. Injury Prevention and Control: Opioid Overdose. Prescription opioid overdose data. Centers for Disease Control, Atlanta, GA, 2016.
3. Attal N, Cruccu G, Baron R, Haanpaa M, Hansson P, Jensen TS, Nurmikko T. EFNS guidelines on the pharmacological treatment of neuropathic pain: 2010 revision. Eur J Neurol 2010;17(9):113-e88.
4. Baron MJ, McDonald PW. Significant pain reduction in chronic pain patients after detoxification from high-dose opioids. J Opioid Manag 2006;2(5):277-82.
5. Bohnert AS, Valenstein M, Bair MJ, Ganoczy D, McCarthy JF, Ilgen MA, Blow FC. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA 2011;305(13):1315-21.
6. Boscarino JA, Rukstalis MR, Hoffman SN, Han JJ, Erlich PM, Ross S, Gerhard GS, Stewart WF. Prevalence of prescription opioid-use disorder among chronic pain patients: comparison of the DSM-5 vs. DSM-4 diagnostic criteria. J Addict Dis 2011;30(3):185-94.
7. Campbell G, Nielsen S, Bruno R, Lintzeris N, Cohen M, Hall W, Larance B, Mattick RP, Degenhardt L. The Pain and Opioids IN Treatment study: characteristics of a cohort using opioids to manage chronic non-cancer pain. Pain 2015; 156(2):231-42.
8. Case A,Deaton A. Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century. Proc Natl Acad Sci USA 2015; 112(49):15078-83.
9. Cherkin DC, Anderson ML, Sherman KJ, Balderson BH, Cook AJ, Hansen KE, Turner JA. Two-Year Follow-up of a Randomized Clinical Trial of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care for Chronic Low Back Pain. JAMA 2017;317(6): 642-4.
10. Cherkin DC, Sherman KJ, Balderson BH, Cook AJ, Anderson ML, Hawkes RJ, Hansen KE, Turner JA. Effect of Mindfulness-Based Stress Reduction vs Cognitive Behavioral Therapy or Usual Care on Back Pain and Functional Limitations in Adults With Chronic Low Back Pain: A Randomized Clinical Trial. JAMA 2016;315(12):1240-9.
11. Chou R, Deyo R, Devine B, Hansen RL, Sullivan S, Jarvik JG, Blazina I, Dana T, Bougatsos C, Turner J. The effectiveness and risks of long-term opioid treatment of chronic pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2014 Sep. (Evidence Reports/Technology Assessments, No. 218). Report No.: 14-E005-EF.
12. Chou R, Deyo R, Friedly J, Skelly A, Hashimoto R, Weimer M, Fu R, Dana T, Kraegel P, Griffin J, Grusing S, Brodt E. Noninvasive Treatments for Low Back Pain 2016, Comparative Effectiveness Reviews, No. 169. Rockville (MD): Agency for Healthcare Research and Quality (US): 2016 Feb. Report No.: 16-EHC004-EF
13. Cunningham JL, Evans MM, King SM, Gehin JM, Loukianova LL. Opioid Tapering in Fibromyalgia Patients: Experience from an Interdisciplinary Pain Rehabilitation Program. Pain Med 2016;17(9):1676-85.
14. Dillie KS, Fleming MF, Mundt MP, French MT. Quality of life associated with daily opioid therapy in a primary care chronic pain sample. J Am Board Fam Med 2008;21(2):108-17.
15. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, Weisner CM, Silverberg MJ, Campbell CI, Psaty BM, Von Korff M. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152(2): 85-92.
16. Eriksen J, Sjogren P, Bruera E, Ekholm O, Rasmussen NK. Critical issues on opioids in chronic non-cancer pain. An epidemiological study. Pain 2006;125:172-9.
17. Finlayson RE, Maruta T, Morse RM, Martin MA. Substance dependence and chronic pain: experience with treatment and follow-up results. Pain 1986;26(2):175-80.
18. Frank JW, Lovejoy TI, Becker WC, Morasco BJ, Koenig CJ, Hoffecker L, Dischinger HR, Dobscha SK, Krebs EE. Patient Outcomes in Dose Reduction or Discontinuation of Long-Term Opioid Therapy: A Systematic Review. Ann Intern Med 2017;167(3):181-91.
19. Goldenberg DL, Clauw DJ, Palmer RE, Clair AG. Opioid Use in Fibromyalgia: A Cautionary Tale. Mayo Clin Proc 2016;91(5):640-8.
20. Gomes T, Mamdani MM, Dhalla IA, Paterson JM, Juurlink DN. Opioid dose and drug- related mortality in patients with nonmalignant pain. Arch Intern Med 2011;171(7):686-91.
21. Han B, Compton WM, Blanco C, Crane E, Lee J, Jones CM. Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health. Ann Intern Med 2017;167(5):293-201.
22. Hooten WM, Townsend CO, Sletten CD, Bruce BK, Rome JD. Treatment outcomes after multidisciplinary pain rehabilitation with analgesic medication withdrawal for patients with fibromyalgia. Pain Med 2007;8(1): 8-16.
23. Kamper SJ, Apeldoorn AT, Chiarotto A, Smeets RJ, Ostelo RW, Guzman J, van Tulder MW. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain. Cochrane Database Syst Rev 2014(9):
24. Noble M, Treadwell JR, Tregear SJ, Coates VH, Wiffen PJ, Akafomo C, Schoelles KM. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010(1):
25. Palmer RE, Carrell DS, Cronkite D, Saunders K, Gross DE, Masters E, Donevan S, Hylan TR, Von Kroff M. The prevalence of problem opioid use in patients receiving chronic opioid therapy: computer-assisted review of electronic health record clinical notes. Pain 2015;156(7):1208-14.
26. Paulozzi LJ. CDC Grand Rounds: Prescription Drug Overdose, a U.S. Epidemic Morbidity and Mortality Weekly Report (MMWR), 2012; 61(01);10-13.
27. Richmond H, Hall AM, Copsey B, Hansen Z, Williamson E, Hoxey-Thomas N, Cooper Z, Lamb SE. The Effectiveness of Cognitive Behavioural Treatment for Non-Specific Low Back Pain: A Systematic Review and Meta-Analysis. PLoS One 2015;10(8):e0134192.
28. Schaafsma F, Schonstein E, Whelan KM, Ulvestad E, Kenny DT, Verbeek JH. Physical conditioning programs for improving work outcomes in workers with back pain. Cochrane Database Syst Rev 2010(1):Cd001822.
29. Sjogren P. Epidemiology of chronic pain and critical issues on opioid use. Pain 2011;152(6): 1219-20.
30. Toblin RL, Mack KA, Perveen G, Paulozzi LJ. A population-based survey of chronic pain and its treatment with prescription drugs. Pain 2011;152(6):249-55.
31. Vowles KE, McEntee ML, Julnes PS, Frohe T, Ney JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain 2015;156(4): 569-76.

Filed under: General Problems