By Pat Anson, Editor
The backlash against opioid medication has gone too far and is depriving chronic pain patients of a treatment many have used successfully for years, according to a commentary published in a prominent medical journal. The article also questions the use of the term “opioid epidemic” in describing the nation’s festering drug problem.
“The movement to virtually eliminate opioids as an option for chronic pain refractory to other treatments is an overreaction,” wrote Kurt Kroenke, MD, and co-author Andrea Cheville, MD, in JAMA. “Many patients currently receiving long-term opioids were started when opioids were still considered a viable treatment option and if satisfied with their pain control and using their medications appropriately should not be unilaterally compelled to wean off opioids.”
Kroenke is a research scientist at the Regenstrief Institute and a professor at the Indiana University School of Medicine. Cheville is a professor and chair of research in the Department of Physical Medicine and Rehabilitation at the Mayo Clinic. She was recently elected to the National Academy of Medicine.
Kroenke and Cheville say many of the medications recommended as safer alternatives to opioids, such as acetaminophen and NSAIDs, provide little pain relief and have risky side effects. Others, such as pregabalin, gabapentin and antidepressants, may work for some pain disorders but have little benefit for others.
“Many patients respond better to one analgesic than another, just as patients with other medical conditions have differential medication responses,” they wrote. “Given the small analgesic effect on average of most pain drugs, the few classes of analgesic options, and the frequent need for combination therapy, eliminating any class of analgesics from the current menu is undesirable.”
Kroenke and Cheville say only a small minority of pain patients who start using opioids go on to use them long-term, yet medical literature and the mass media are filled with references to the so-called “opioid epidemic.”
“Excessive use of phrases like opioid epidemic should be avoided. An epidemic generally suggests a disease that is widespread and usually highly contagious rather than limited to a minority of those exposed,” they said. “Most patients receiving an initial opioid prescription do not proceed to chronic use and among the subset that do use long-term opioids, the majority neither misuse nor experience an overdose.
“An unintended consequence of excessive concerns raised about opioids could be an increasing reluctance among clinicians to prescribe even small amounts of opioids for a limited time for acute pain, including for patients discharged from the emergency department, those who are recuperating from surgical procedures, or persons with severe dental pain.”
A bill recently introduced in Congress would strictly limit opioids to just 7 days for acute pain, a prescription that could not be renewed. Maine, New Jersey, Ohio and several other states are adopting similar measures to limit opioid prescribing.
Kroenke and Cheville say few long-term studies have been conducted on the safety and effectiveness of any pain medications, and more research is needed on alternative therapies like cognitive behavioral therapy and medical marijuana before opioids are abandoned as a treatment option.
“Clinicians must be careful of replacing the opioid epidemic with a marijuana epidemic,” they warned. “Imperfect treatments do not justify therapeutic nihilism. A broad menu of partially effective treatment options maximizes the chances of achieving at least partial amelioration of chronic pain.”