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Editorial |

Opioids for Chronic Pain

Deborah Grady, MD, MPH; Seth A. Berkowitz, MD; Mitchell H. Katz, MD
Arch Intern Med. 2011;171(16):1426-1427. doi:10.1001/archinternmed.2011.213.
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As practicing physicians, we have observed that the problems associated with opioid medications for the treatment of chronic pain are growing rapidly. In primary and specialty care, chronic nonmalignant pain is common, with 20% to 40% of adults reporting chronic pain.1 Opioids are the most common means of treatment for chronic pain; 15% to 20% of office visits in the United States now include the prescription of an opioid,1 and 4 million Americans per year are prescribed a long-acting opioid.2 Opioids have become the most commonly prescribed drug category in the United States, and the increasing prevalence of their prescription closely parallels the increasing emphasis, which began in the mid-1990s, on treatment of chronic pain.24 A partial explanation of why we got to this point is that the lessons learned from the undertreatment of pain in patients with cancer were generalized to patients with chronic pain and no clear end point of cure or death. The practice of using opioids for chronic pain treatment also has been reinforced by continuing medical education classes and state regulations5 encouraging physicians to adequately treat pain.

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In defense of opioids for chronic pain
Posted on September 26, 2011
David L. Keller, M.D.
Providence Medical Institute
Conflict of Interest: None Declared
In response to the editorial “Opioids for Chronic Pain” (1): 1) The authors distinguish between patients with chronic pain, and patients whose painful condition has a “clear end point of cure or death” (e.g. cancer). They propose restricting or denying opioid prescriptions for chronic pain patients. I disagree. If a patient with severe chronic pain might obtain some relief from opioid therapy, it is wrong to deny the patient that choice.
2) The authors argue that opioids only reduced pain scores by approximately 30% in clinical trials. Why not let the patient decide whether a 30% reduction in pain is worth the side effects and risks of opioid therapy? The degree of pain reduction is subjective and varies between individuals.
3) Overdose deaths caused by opioid abuse are tragic, but we should not allow the misdeeds of criminals to hamper the treatment of innocent pain patients. Doctors should educate patients on the safe use of opioids, as with other drugs which can cause overdose deaths (e.g. warfarin, insulin). If a patient requires a higher dose of opioid than their physician is comfortable prescribing, they should be referred to a pain specialist.
4) The authors argue that government regulations make it too burdensome for physicians to prescribe strong opioids, which require monthly visits and non-refillable scripts. We should work to reform those regulations, not use them as an excuse to undertreat pain patients.
5) The authors advocate trying NSAID's, anti-depressants, and physical therapy before prescribing opioids. However, some patients are in too much pain to tolerate physical therapy. Depression caused by unrelenting physical pain may not remit until the pain is treated. And NSAID's can worsen hypertension, coronary disease, renal insufficiency, peptic ulcer disease and congestive heart failure. Opioids can be prescribed safely in these conditions. Adjunctive treatments should supplement, not replace, the opioids which are the core therapy for severe pain.
It is true that physicians need to exercise greater care when prescribing strong opioids, but to deny or restrict opioids for chronic pain patients is not humane or sensible.
Reference:
1) Grady D, Berkowitz SA, Katz MH, Opioids for Chronic Pain, Arch Intern Med. 2011; 171(16): 1426-1427

Conflict of Interest: None declared
The Authors Reply to Dr. Keller
Posted on October 20, 2011
Seth A. Berkowitz, MD
Division of General Internal Medicine, University of California, San Francisco,
Conflict of Interest: None Declared
We wish to thank Dr. Keller for his thoughtful comments and feedback on such a complicated issue. Caring for patients with chronic pain is one of the most challenging things we do as physicians, and all of us who do so are frustrated by the lack of safe, highly effective therapies.
We believe that the heart of our disagreement with Dr. Keller can be found in his 5th point, namely that “Adjunctive treatments should supplement, not replace, the opioids which are the core therapy for severe pain.” While this paradigm has wide currency, one cannot simply extrapolate from the efficacy of opioids in treating acute nociceptive pain in, for example, the post-surgical setting, to that of chronic non- malignant pain of unclear etiology. Unfortunately, research cited to support the efficacy of opioids for chronic pain(1) uses outcomes of unclear significance, makes no real attempt to weigh benefits and harms, and bears little resemblance, in either duration of therapy or dose of medications, to real world practice. Until these gaps in the literature are filled, we feel it is premature to consider opioids the “core therapy” for chronic non-malignant pain.
We also disagree that adverse consequences of opioid therapy occur only in “criminals”, leaving “innocent pain patients” unscathed. Rather, we feel that the harms of opioid therapy, including abuse, overdose, and death, are predictable side effects of therapy to which any patient may be susceptible. Education about these risks should be an important part of therapy, but it is unclear if this is fully (or even partially) protective. While physicians commonly use therapies that can be dangerous, this is generally only done when efficacy is well established and the risks of no treatment are high. In our opinion, the evidence that insulin and warfarin are beneficial if used correctly for their respective indications is substantially more robust than that of opioids for chronic non-malignant pain.
The only acceptable goal of therapy in patients with chronic non- malignant pain is the relief of their suffering. From this, however, it simply does not follow that ever-increasing doses of opioids are the appropriate therapy. We can all agree that further research identifying safe and effective ways to treat patients with chronic pain, using opioids and other agents, is warranted.
1. Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. Feb 2009;10(2):113-130.

Conflict of Interest: None declared
The need to take patients' values into account
Posted on September 18, 2011
James R Mosenfelder, patient, bachelor of philosophy
none
Conflict of Interest: None Declared
The facts and statistics demonstrating the risks associated with opioid pain medications may be correct, but you seem to fail to take the patient's values into account. What is a chronic pain patient to do following the suggested "sobering talk" from his or her doctor? Go home and suffer? There is a very real difference between "I can't make the pain go away" and "I won't offer treatment that may reduce the pain because I don't think you should have the option to take the risks." When the patient is an adult and a responsible person, he or she deserves a say in what risks are acceptable. For some of us, the risk of adverse reactions, including the possibility of death may be preferable to the certainty of suffering 24 hours per day possibly for the remainder of our lives. Should the doctor, or the medical society, substitute their assumption that death is the worst possible outcome for the patient's own view of what is in his or her best interest? What of the patient who has tried every reasonable alternative without adequate relief? Physical therapy, yoga, counseling, and so forth should certainly be offered, but for many, they result in little relief. I have tried all of these and none have significantly reduced my pain. In my view, telling the patient to go away and suffer does not fulfill the maxim "be of use". Conflict of Interest: Currently receiving treatment for chronic neuropathic pain, including oximorphone.
Clarification
Posted on November 13, 2011
David L. Keller, MD
Providence Medical Group
Conflict of Interest: None Declared
I fully agree with the authors that research is needed to develop better options for treating patients with chronic pain. I wish to clarify my use of the term "criminal" in my original letter, by which I meant persons who lie to physicians or feign pain syndromes in order to obtain opioids for illegal purposes, and also physicians who violate the law by knowingly prescribing opioids for resale or abuse.
Conflict of Interest: None declared
Opioids should not be denied when they are needed for pain
Posted on February 21, 2014
David L. Keller, MD, MS
no affiliation
Conflict of Interest: None Declared
In response to the editorial “Opioids for Chronic Pain”:1) The authors distinguish between patients with chronic pain, and patients whose painful condition has a “clear end point of cure or death” (e.g. cancer). They propose restricting or denying opioid prescriptions for chronic pain patients. I disagree. If a patient with severe chronic pain might obtain some relief from opioid therapy, it is wrong to deny the patient that choice.2) The authors argue that opioids only reduced pain scores by approximately 30% in clinical trials. Why not let the patient decide whether a 30% reduction in pain is worth the side effects and risks of opioid therapy? The degree of pain reduction is subjective and varies between individuals.3) Overdose deaths caused by opioid abuse are tragic, and we need to work harder to prevent them. At the same time, we are obligated to relieve suffering, and if opioids are required, then they should be an option. Doctors need to educate patients on the safe use of opioids, as with other drugs which can cause overdose deaths (e.g. warfarin, insulin). If a patient requires escalating doses of opioids, or if their physician is uncomfortable about their treatment for any reason, they should be referred to a pain specialist.4) The authors argue that government regulations make it too burdensome for physicians to prescribe strong opioids, which require monthly visits and non-refillable scripts. We should work to reform those regulations, not use them as an excuse to under-treat pain patients.5) The authors advocate trying NSAID's, anti-depressants, and physical therapy before prescribing opioids. However, some patients are in too much pain to tolerate physical therapy. Depression caused by unrelenting physical pain may not remit until the pain is treated. And NSAID's can worsen hypertension, coronary disease, renal insufficiency, peptic ulcer disease and congestive heart failure. Opioids can often be prescribed safely in these conditions when NSAID's cannot. Adjunctive treatments should supplement opioids which are required for severe pain, with the goal of tapering the opioids as tolerated.It is true that physicians need to exercise greater care when prescribing strong opioids, but to deny or restrict opioids for chronic pain patients is not humane or sensible.
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