Opioids for the Treatment of Chronic Pain… Use or Abuse?

In the United States, chronic pain affects more than 100 million people – which accounts for almost a third of the population. But despite how common chronic pain is, an Institute of Medicine Report estimates that 40 to 70% of chronic pain patients do not have their pain adequately treated. In the past twenty years, increasing awareness of this issue among doctors as well as increasing demand for better pain care among patients had lead to a rise in the number of prescriptions being written for opiates (narcotics). Unfortunately, during the same time period, there has also been a three to five fold increase in overdose related deaths and injuries, as well as a rise in levels of addiction.

Because chronic pain is not unusual in patients living with rheumatoid arthritis and other types of chronic conditions, this is an important topic for rheumatologists and rheumatology health care professionals. For that reason, there was a debate held on the subject at the American College of Rheumatology’s annual meeting in San Francisco, California on November 9, 2015. The question being debated by two prominent doctors was this: can doctors safely prescribe opiates for chronic non-cancer pain?

Dr. Daniel Clauw, a Professor of Anesthesiology, Medicine (Rheumatology), and Psychiatry at the University of Michigan delivered the argument against the use of opiates for managing chronic non-cancer pain. The fist question he discussed was whether opioids are even effective in the treatment of chronic pain. While he granted that opioids work fairly well for most individuals with very acute pain, Dr. Clauw argued that there is a dearth of data regarding the effectiveness of opioids for treating chronic pain. According to available data, most opioids have only been shown to be effective in treating a single chronic pain condition. Nevertheless, due to regulatory precedent, these medications are often approved for use in any type of chronic pain. Dr. Clauw maintained that these flaws in study design and labeling have allowed pharmaceutical companies to market opiates to anyone with chronic pain, regardless of efficacy. Overall, he thinks this has done more harm than good.

The United States has roughly 4% of the world’s population, but now consumes over 80% of the world’s opioids. In 2013, more than 16,000 individuals died from overdose of prescription opiates, as compared to 7,000 who died from the illegal drug heroin. Dr. Clauw pointed out that these statistics also represent the best-case scenario, since death certificates do not always record the specific cause of “overdose.” In addition, Dr. Clauw reminded the audience that prescription opioids often serve as a gateway to heroin use, as 75% of heroin users first experience with an opioid is a prescription one. Additionally, the switch to heroin is often economically driven, as heroin can actually be cheaper to obtain.

Dr. Clauw’s conclusion was that opioids should be used as a very last option for some types of chronic non-cancer pain, but that he didn’t think doctors were being careful enough in choosing the right types of patients. He warned doctors in the audience to consider the downstream consequences every time they prescribe an opiate. Not only is there a risk that the patient may abuse the medication, there is also a problem with diversion, where the prescription opiates end up in the hands of people other than to whom they were prescribed. This is particularly problematic in cases where doctors write big prescriptions to avoid the hassle of writing multiple prescriptions. Dr. Clauw contended that this over-prescribing needs to be reigned in to protect society. He compared opiates to guns – although the police may use guns to protect us, they can also be very dangerous in the wrong hands.

Dr. John Markman, director of the Translational Pain Research Program in the Department of Neurosurgery and Professor at the University of Rochester School of Medicine, delivered the argument in favor of using opiates as an option to treat chronic non-cancer pain. Like antibiotics being used to treat a bacterial infection, he argued that opioids are nothing more that a tool that, when used properly, may be very helpful to patients living with chronic pain.

However, Dr. Markman did acknowledge that opiates are not appropriate for every patient. He encouraged the doctors in the audience to assess the risk factors for abuse and then prescribe opiates to chronic pain patients when appropriate. He pointed out that if doctors refuse to prescribe opiates outright, they may be “leaving relief on the table.” He also pointed out that most patients do not wish to take opiates or stay on them over the long term, and that many patients can be trusted to use opiates appropriately.

Overall, Dr. Markman maintained that it doesn’t really make sense for doctors to be “for” or “against” opiates. Instead, he argued it only makes sense for doctors to be “for” their patients – which means using whatever tools are available to get the best possible outcomes for patients. Dr. Markman contended that the abuse rhetoric surrounding discussions of prescription opiates can actually also be dangerous for patients, as it may keep opiates away from patients who could greatly benefit from their use.

Instead of the gun metaphor, Dr. Markman encouraged doctors to see opiates as a car. A car is a tool that can be highly beneficial, though it does also have the potential to be dangerous. However, rather than forbidding cars all together, we work to make them safer. We give only certain people permission to drive them. This is the approach Dr. Markman recommended for opiates in order to provide the best outcome for patients living with chronic pain.

This activity is not sanctioned by, nor a part of, the American College of Rheumatology.

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