Opioid Therapy: Do the Promises Outweigh the Pitfalls?

As a nation, Denmark is the largest consumer of opioids per capita and by virtue of their socialized healthcare system, they are able to produce reams of data on practically any healthcare-related undertaking in the country.

Accordingly we know that 19% of patients there experience chronic pain and of those, 12% require opioids for their pain. Though that may be the case, an analysis of that data, examining whether patients on opioid therapy were better off than their non-opioid counterparts, found that there were no differences in quality of life issues between the two groups.

Using these findings, presenters at the American Academy of Pain Medicine’s 26th annual meeting continue to debate whether, in the face of such evidence, use of prescription opioids is really the most effective method of pain control. Further, they seem to wonder whether the mere availability of prescription opiods through physicians is the driving force behind the problem of opioid abuse in the United States. Whatever the reasons behind opioid abuse in America, there now exists a climate in which it is becoming increasingly prohibitive for patients who would truly benefit from opioids to acquire and sustainably take them. Certainly if the federal government has its way with REMS, that could become an unfortunate status quo.

Presenters today all seem to agree that in order to prevent opioid abuse, an opioid agreement is one of the most effective deterrents in patients with chronic non-malignant pain. One presenter here indicated that he has never had to "fire" a patient over non-compliance with an agreement, and that true opioid abusers will self-discharge once they realize that they can’t readily get what they want.

Questions of opioid efficacy aside, there really seems to be a presumption of guilt by doctors when it comes to patient opioid abuse. I'm not sure how to feel about this because on the one hand, there is a real risk for abuse and diversion, but that has to be balanced against the needs of the patient. This becomes problematic when you consider the data, which indicates that, long term, opioids are not overly effective in the relief of chronic pain.

What bothers me most is that a lot of the discussion thus far has focused on tools that physicians can use to identify aberrant behavior in patients, with little discussion of the efficacy of alternative therapies prior to initiation of opioid therapy.

So why is there this disconnect? Consider: 1) There is a potential for opioid abuse on the part of patients and many physicians recommended that a doctor implement an opioid agreement to prevent such abuse, 2) opioids have not demonstrated strong efficacy in pain relief over the long term, 3) patients in large part experience adverse events while on opioids.

Taking all of that into account, why prescribe opioids in the first place?

I continue to ask myself this question, especially in light of the many post-presentation comments and questions that I heard today from clinicians in the field. Almost all centered on strategies for managing tolerance and abuse. These questions, the research presented today, and the tone of many presentations, make it seem as if physicians would be better off using non-opioid therapies to manage patient pain. It’s frustrating to hear the similar refrains over and over: “What do you do when a patient’s urine screen comes back positive for something you didn’t prescribe?” “How do I handle a patient who escalates dosage on their own?” “This patient keeps crying to me that they’ll go into withdrawal if I take away their opioids.”

And again I ask myself the question: why prescribe opioids in the first place?

Because in many patients, they work. The problem is identifying which patients will respond favorably to opioid therapy (not to mention figuring the correct formulation, dosage, frequency, etc.) and how to effectively manage those that won’t. And I know that’s not just something I’m asking. The pain community continues to struggle with this issue and will debate it over the course of this week.

For all the latest on the subject, keep checking back here. I’ll keep you posted.