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Medical society warns against use of opioids for chronic noncancer pain

People with headache, lower back pain, fibromyalgia or other noncancer condition should not be prescribed prescription pain medications known as opioids — drugs like oxycodone, hydrocodone, fentanyl and morphine — because the risks far outweigh any benefits, according to a new policy statement issued Monday by the American Academy of Neurology.

The paper, written by Dr. Gary Franklin of the University of Washington in Seattle and published in the journal Neurology, also calls on primary care physicians — who are the principal prescribers of opioids — to assess their patients more carefully while they are on these drugs and to refer any chronic pain patients to specialists if they are taking daily doses that are the equivalent of 80 to 120 milligrams of morphine.

This is the first position paper on prescription opioids issued by a major American medical specialty society. It was published just as the National Institutes of Health convened a two-day meeting of experts on the role of opioids in the treatment of chronic pain and a day after 1,000 activists rallied in Washington, D.C., demanding that the Obama administration and federal agencies do more to curb the pharmaceutical industry’s ongoing efforts to expand the use of prescription opioids.

Many of those activists were the bereaved relatives of the more than 100,000 Americans who have died since the late 1990s from prescription opioid overdoses. As Franklin points out in the position statement, that’s far more than the number of U.S. military deaths during the Vietnam War (58,000).

In fact, deaths in the U.S. from opioid overdoses now exceed 16,000 per year. Among people aged 35 to 54, prescription opioids claim more lives than either firearms or motor vehicle accidents.

“A couple days ago, President Obama gave a speech about Ebola and said we have to do everything we can about the epidemic, and, of course, we do,” one of the activists who marched last Sunday in Washingon told the Washington Post. “But about 3,000 West Africans have died from that epidemic. … In the United States during that same time frame, we’ve had 30,000 Americans die from drug overdoses.”

Huge profits

For decades, the long-term use of opioids for treating noncancer chronic pain (lasting more than three months) was prohibited in most states. That changed, however, in the late 1990s, when the pharmaceutical industry successfully lobbied state legislatures to liberalize opioid use to include the treatment of conditions that cause long-term as well as short-term pain. Physicians and patient advocacy groups with strong financial ties to opioid manufacturers helped greatly with that lobbying effort.

Sales skyrocketed to more than $9 billion a year — but so did overdose deaths from the drugs, which quadrupled within a period of just 12 years, from 4,030 deaths in 1999 to 16,651 in 2010. The drugs also exacted an enormous economic cost on the U.S. economy. The CDC estimates, for example, that the non-medical use of prescription opioids costs health insurers alone more than $72 billion annually in direct medical costs.

The liberalizing of the use of prescription opioids was done, however, without any good evidence that the drugs were all that effective for helping people get rid of their chronic pain. And, indeed, recent independent (non-drug-company-sponsored) studies have shown that the drugs do little, if anything, to reduce chronic pain or to improve the ability of people with such pain to function better in their everyday lives.

The studies have shown, however, that when people are put on prescription painkillers, they tend to stay on them. About half of patients who are prescribed opioids for at least three months are still on the drugs five years later.

Significant risks

Prescription painkillers have also been found to pose a long, long list of health risks. In addition to the increased risk of death from overdose, potential side effects include constipation, nausea, dizziness, drowsiness, infertility, suppression of the immune system, falls and bone fractures (among older adults) and heart problems.

“It seems likely that, in the long run, the use of opioids chronically for most routine conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not prove to be worth the risk,” writes Franklin in the position paper. “However, even for more severe conditions, such as destructive rheumatoid arthritis, sickle-cell disease, severe collagen disease, or severe neuropathic pain, prescribers need specific guidance on dosing, publicly available brief tools to effectively screen patients for risk, and guidance on how to monitor patients for early signs of severe adverse events, misuse, or opioid use disorder.”

Franklin also notes in his paper that “reversing current opioid overdose epidemic trends will not be easily accomplished by informal or even mandatory education alone.” Many states have tried those tactics for years, with little effect, he points out.

What needs to happen is a revision of state and federal laws and policies, he stresses.

You can read the AAN position paper on Neurology’s website.

Comments (1)

  1. Submitted by Greg Kapphahn on 10/03/2014 - 08:19 am.

    Recent Experience with Hydrocodone

    While waiting for an appointment with a Podiatrist who diagnosed me yesterday with gout, my GP prescribed hydrocodone-acetominophen for the pain I was suffering.

    I, who generally have a very high threshold of pain was having what I judged to be level 8 pain, and having a very difficult/painful time walking, so I was hoping for some relief. The hydrocodone never took me below level 6 (which was a BIT better), with the first half dose doing the most good and the next full doses each helping less while the side effects grew worse,…

    those side effects causing my brain to slip a cog fairly often so that I didn’t notice obvious mistakes in what I was doing until well after I made them (if at all), and making me want to nod off in the middle of whatever I was trying to do.

    Luckily my podiatrist appointment was only 24 hours after that with my GP, and the Podiatrist prescribed an immobilizing boot and switched me to massive doses of a timed-release NSAID (which may have its own issues) but seems to be helping considerably MORE then the hydrocodone-acetominophen.

    Even though I only took it for 24 hours, I still suffered uncomfortable levels of nausea for 12 hours after I stopped taking the hydrocodone-acetominophen, (strong enough that I was too nauseous to eat supper last night), …

    a symptom which I took to be a mild form of withdrawal.

    I hope I’ll never need to take an opioid again. I probably should avoid them, anyway, since, when she was in her middle 80’s, my grandmother was prescribed one to help with the pain of having shingles and completely lost her mental orientation as a result.

    Thank God she was already temporarily in a nursing home and not alone at home when this happened. She was mentally back to normal within a couple of weeks as soon as she stopped taking it and it completely cleared from her system.

    I once had a different elderly person I knew stopped by law enforcement in the middle of the night, driving around, half dressed, in the small town where we lived, looking for long-dead relatives, as a result of taking opioids for pain.

    Luckily she came back to normal, as well, as soon as the opioid was out of her system.

    Perhaps our medical personnel need to stop prescribing opioids so casually, and regard them as a 2nd or 3rd or even last choice in the treatment of pain.

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