The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention WorkshopFREE
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Abstract
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Data Extraction and Quality Assessment
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Long-Term Effectiveness
Harms
Opioid Abuse, Addiction, and Related Outcomes
Overdose
Fractures
Cardiovascular Events
Endocrinological Harms
Motor Vehicle Accidents
Other Harms
Opioid Dosing Strategies
Initiation of Opioid Therapy and Titration of Doses
Comparative Effectiveness and Harms of Long-Acting Opioids
Dose Escalation
Other Opioid Dosing Strategies
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The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med.2015;162:276-286. [Epub 17 February 2015]. doi:10.7326/M14-2559
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Long-Term Opioid Therapy for Chronic Pain: But What Drives Prescribing?
In the late 1990s, The Joint Commission (TJC) made well-intended recommendations that pain be better recognized (2). The American Pain Society subsequently developed a Pain Care Bill of Rights and promoted pain as a “fifth vital sign.” Other organizations followed suit, including the Veterans Administration which published a “Pain as the 5th Vital Sign Toolkit” in 2000, further justifying the use of opiates for non-malignant pain. The opiate-boom began.
With this modern culture of opiate prescribing, we have seen an incongruity between physician treatment goals and the perceptions that patients have regarding the management of their pain (3). These situations inevitably result in patient-provider conflict. Face-to-face requests for opiates by patients often contradict a number of practice guidelines suggesting non-pharmacologic or non-opioid alternatives for pain. Most patients do not have formal medical training and are largely unaware of what constitutes “quality” medical care, or of adverse medication effects.
In the world of pain management, patient satisfaction surveys may lead to unintended consequences. Government programs now look to patient satisfaction as a surrogate for healthcare quality. For example, Medicare reimbursements partially rely on this metric as part of the CMS Hospital Inpatient Value-Based Purchasing program (4). Not only are physician salaries subject to adjustment based on these data but promotion delays or termination may occur as a result. Overworked physicians with very little time are therefore heavily incentivized to meet their patient’s expectations by prescribing opiates (5). Pain is a vital sign, after all.
While Chou and colleagues make a number of salient suggestions for reducing harms of long-term opioid therapy, we may never be fully successful in curbing these risks without addressing the causes of opiate prescribing. Concerns regarding patient demand, patient satisfaction, and quality measures serve to further complicate this, and deserve attention as our government moves to alter reimbursement without consideration for clinical reality.
References;
1. Chou R, Turner JA, Devine EB, Hansen RN, Sullivan SD, Blazina I, Dana T, Bougatsos C, Deyo RA.The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. 2015 Jan 13. [Epub ahead of print]
2. Joint Commission on Accreditation of Healthcare Organizations. Pain assessment and management: an organizational approach. Oakbrook Terrace, IL: Joint Commission on Accreditation of Healthcare Organizations, 2000.
3. Frantsve LME, Kerns RD. Patient-provider interactions in the management of chronic pain: current findings within the context of shared medical decision making. Pain Med. 2007; 8(1):25–35.
4. Hospital Inpatient Value-Based Purchasing Program [Centers for Medicare & Medicaid Services web site]. Available at:http://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/2011-10568.pdf
5. Zgierska A, Miller M, Rabago D. Patient satisfaction, prescription drug abuse, and potential unintended consequences. JAMA. 2012 Apr 4;307(13):1377-8.
Narcotic Prescribing, Benefits and Risks
The trend is commonly blamed on irresponsible prescribing. As an unintended consequence of the blame, many younger physicians refuse to prescribe narcotics for people with chronic pain. Not for anyone. Not for any pain. The result is that pain is the only treatable condition I can think of that many physicians deliberately will not treat.
"The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain" (Ann Intern Med 2015;162:276-286) perpetuates the negative image of narcotic prescriptions for chronic pain. In a review of 4209 English-language articles, the authors could find no study of the long-term outcomes related to pain, function, or quality of life. Not one. The article is then given over entirely to a discussion of risks. But risk, alone, is never the basis for a physician's or a patient's decision. It is always the balance of risk versus benefit. Omission of discussion of benefit from an article on the effectiveness and risks of therapy is, at a minimum…curious.
There are other curious problems with the article. It speaks of overdose deaths as if all deaths were the same. There’s no mention of the tragic deaths of children who sample parent’s medicines with lethal results. It doesn’t recognize that some overdose deaths are suicides. Chronic pain can cause patients to lose jobs, self-sufficiency, family, all their belongings and hope. Suicides in patients with chronic pain are not surprising.
There’s no mention of diverted narcotics, prescribed for pain, becoming gateway drugs for heroin.
The article speaks of heightened ED drug use in narcotic-treated patients as a possible indicator of opoid-induced sexual dysfunction. Another hypothesis is that pain impairs sexual appetite. Treatment of that pain can allow sexual activity to rebound, uncovering the ED problem.
The article speaks of increased risk of myocardial infarction in narcotic-treated people. Is it the narcotic? Or the changes in activity and diet, forced by pain, that increases the risk?
And so on.
In the end, the article might have closed by pointing out the similarities between narcotics and alcohol. The great majority of people who use alcohol, and of people who are prescribed narcotics, use them responsibly. A minority don’t. The minority attracts all the attention.
Many older physicians…and I…still prescribe narcotics for our patients who have significant chronic pain, despite acknowledged risks. We believe it’s the right thing to do.
In response
As Dr. Retan notes, we identified no studies meeting pre-defined inclusion criteria on the effectiveness of long-term opioid therapy for chronic pain. He does not describe any studies that we overlooked. Therefore, it is unclear what evidence he believes should have been included to discuss long-term benefits. For mortality and overdose-related events, it was generally not possible for studies to exclude cases due to intentional suicide attempts, though the authors controlled for psychological diagnoses and psychiatric medication use.2, 3 For these and other harms, we described limitations of the evidence, including the inability to completely address potential confounders and (in the case of endocrine-related adverse events) the reliance on a surrogate outcome (use of medications for erectile dysfunction and testosterone replacement).4 We describe the associations as reported in the studies and did not speculate about the underlying causes of myocardial infarction or other harms.
High levels of scrutiny for opioid prescribing are warranted based on the substantial increases in opioid-related deaths and prescription opioid abuse.5 It does not seem appropriate, as Dr. Retan states, to equate alcohol use, a substance used recreationally, with long-term opioid therapy, a drug prescribed for medical purposes. Curiously, while downplaying the harms of opioids, Dr. Retan at the same time notes additional harms related to diversion and sampling of opioids by family members and friends and critiques our review for not addressing them. To clarify, our review focused on benefits and harms in persons prescribed opioids. However, we are unaware of any study that has attempted to estimate the harms related to diversion and sampling of opioids from persons prescribed versus not prescribed opioids, or evaluated dose-dependent effects on such outcomes.
1. Reuben DB, Alvanzo AA, Ashikaga T, et al. National Institute of Health Pathways to Prevention Workshop: The rold of opioids in the treatment of chronic pain. Ann Intern Med 2015;162:295-300.
2. Dunn KM, Saunders DW, Rutter CM et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med 2010;152:85-92.
3. Gomes T, Mamdani MM, Dhalla IA et al. Opioid dose and drug-related mortality in patients with nonmalignant pain. Arch Intern Med 2011;17:686-91.
4. Deyo RA, Smith DH, Johnson E, et al. Prescription opioids for back pain and use of medications for erectile dysfunction. Spine 2013;38:909-15.
5. Okie S. A flood of opioids, a rising tide of deaths. N Engl J Med 2010;363:1981-5
Disclosures: Research funding from the Agency for Healthcare Research and Quality to conduct the review that is the subject of the correspondence