Opioids for chronic noncancer pain discouraged

By Caroline Price

US experts have called for more selective and cautious opioid prescribing for chronic noncancer pain, because of concerns over misuse of the drugs and continued uncertainty over when and for how long they should be prescribed.

In a collection of related articles in the current Annals of Family Medicine, they highlight concerns surrounding opioid use and misuse among primary care patients, and the lack of clear guidance on safe use of the drugs in this setting.

Family physicians Roger Rosenblatt and Mary Catlin, from the University of Washington in Seattle, write: "Entering into chronic opioid therapy requires a long-term commitment by clinicians and patient alike to use this powerful, precious, and dangerous medication with care and diligence."

The editorialists explain that the volume of opioids prescribed for chronic noncancer pain in primary care rocketed 600% between 1997 and 2007, while the number of unintentional lethal overdoses involving prescription opioids increased 350% in the same period.

In a research paper, a team led by Mark Sullivan, also from the University of Washington, reports findings from telephone interview-based research in 1334 patients, who had no history of any substance abuse. Those with moderate or severe depression were twice as likely as those without depression to misuse their opioid medications for nonpain symptoms, namely stress or insomnia, and even mildly depressed patients were twice as likely as nondepressed ones to use a higher dose than prescribed.

John Zweifler from the University of California, San Francisco, meanwhile argues in an essay article for a strict standard for initiating opioids for chronic disease: the presence of objective evidence of severe disease. But Rosenblatt and Catlin warn that the original trigger of chronic pain may no longer exist or be impossible to determine - and confirmation by sophisticated imaging techniques may lead to as many false-negative and false-positive diagnoses as the widely used, "much-maligned" visual analog pain scale.

They conclude that "opioids for chronic noncancer pain are not appropriate therapy for most patients in primary care settings," and emphasize that there are safer alternative approaches to opioid therapy available, such as physical therapy, cognitive behavioral therapy, and treatment of co-occurring psychiatric illness.

Finally, in another editorial, Michael Von Korff, from the Group Health Research Institute in Seattle, Washington, describes the key findings from a recent public meeting convened by the US Food and Drug Administration on prescription opioids.

Uncertainty about long-term effectiveness of the drugs for chronic noncancer pain was identified as a major gap in knowledge, he writes, yet guidelines on this produced by palliative care specialists and based almost entirely on expert opinion have been generalized to primary care practice without proper evaluation.

"As the pendulum swings in the direction of more selective and conservative opioid prescribing, it is critical that primary care physicians take the leading role in defining how, when, and for whom opioids should be used in long-term management of chronic pain," concludes Von Korff.

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