American Academy of Neurology Position: Limit Opioids for Chronic Pain

Citing a “public health epidemic” of death and addiction related to use of prescription opioids, the American Academy of Neurology (AAN) calls for a multi-pronged approach to curbing prescriptions. But the group stresses that finding ways to help patients in chronic pain is worthwhile and difficult.

In a position paperwritten at the request of the AAN’s patient safety subcommittee, Gary Franklin, MD, MPH, stopped far short of calling for a ban on their use for patients in chronic pain (other than cancer patients). But Franklin, an AAN fellow and a professor at the University of Washington School of Public Health’s department of environmental and occupational health sciences department, said prescribers should use more caution—particularly when patients’ pain and ability to function do not seem to improve.

The paper comes as federal agencies move to tighten prescribing practices for pain medications. The US Drug Enforcement Agency issued a new rule that takes effect Oct. 6 2014. The DEA is moving drugs that are hydrocodone combination products from its Schedule III classification to Schedule II. Such drugs require a new prescription and cannot automatically be renewed.

In the AAN position paper, Franklin reported on his survey of research which found that there is little evidence that these drugs can be prescribed long term without the attendant risks of drug diversion, overdose, dependence and addiction. Escalating doses when effectiveness wears off only contributes to these risks.

Until the late 1990s, he notes, states banned prescribing these drugs for anyone with chronic pain other than cancer patients. But “pain advocacy groups and groups of pain specialists successfully lobbied state medical boards and legislatures” to overturn those rules. That opened the door to the current wave of overdose deaths, which he says numbered nearly 100,000 in the US from 199 to 2010, with 16,651 such deaths in 2010.

Regulation remains a state function. In July, the US Centers for Disease Control and Prevention (CDC) issued a report showing that US residents get the drugs at a greater rate than any other nation. The CDC also found prescribing patterns for opioids and benzodiazepines varied widely among the states. The agency called on state policy-makers to implement “changes that will make the prescribing of these drugs more cautious and more consistent with clinical recommendations.”

Franklin praised his own state’s approach to fighting overuse of prescription opioids, one that calls on prescribers to contact a pain specialist when a patient’s morphine-equivalent dosage reaches 120 mg/d and pain and function have not improved substantially. Dependency is a common problem, he wrote, citing a study that found that 50% of patients at least 3 months initially were still taking them 5 years later.

When prescribing opioids for chronic pain started, the cases cited by advocates who said the practice would be safe were those of patients taking less than 40 mg/d, he found. But that likely understated the doses that were found necessary. One study showed that among a cohort of injured workers prescribed the drug, average dosage started at 80 mg/d and rose to 140 mg/d from 1996 to 2002.

Franklin’s report focuses on the problems of finding pain medication that works for people with chronic conditions.

He gives less attention to a program started Aug. 27, 2013, in New York State, on that takes a law-enforcement approach, seeing the main need as curbing doctor-shopping and eliminating “pill mills”. It was instituted by NY’s attorney general.

Known as the I-Stop prescription monitoring program it requires prescribers to consult an online patient registry before writing prescriptions for Schedule II, III, and IV controlled substances. The registry shows all such prescriptions the patient has gotten in the prior 6 months—as long as they were written in NY.

The AAN position paper makes note of such programs, saying NY is one of 4 states that mandate use of a prescription drug monitoring program (PDMP) —the others are Kentucky, New Mexico, and Tennessee. Such programs are widely available, but “are underutilized, perhaps due to inadequate guidance as to the most effective/efficient use of these programs, and a perception that accessing the program is burdensome to the physician,” Franklin wrote.

He does recommend that prescribers check patients’ prescriptions on a PDMP database at the time of the first opioid prescription, particularly in that happens in an emergency room. But Franklin also calls for instituting dosing recommendations as part of a “best practices” guideline for primary care providers, since they are the source of most such prescriptions.

Among those are avoiding escalating doses above 120 mg/d unless the patient shows “sustained meaningful improvement in pain and function.” The other suggested practices are screening for past or ongoing conditions that may have involved prescription opioid use, such as post-traumatic stress disorder, depression, and anxiety. He would also like to see patients and prescribers sign a document spelling out patients’ risks and responsibilities in taking such drugs for chronic pain.