NIH Panel: A New Approach to Treating Pain with Opioids

Treating the 100 million Americans living in chronic pain has become an impossible conundrum. Too often, primary care doctors don’t take the time to determine the root cause of a patient’s pain and the result is an overprescribing of an opioid painkiller. That’s the conclusion reached by an independent panel of experts convened by the National Institutes of Health (NIH) in September 2014.

The panel published its recommendations in the January 2015 issue of the Annals of Internal Medicine. Some of the more alarming revelations of the report:

  • The number of opioid prescriptions for pain treatment increased from 76 million Americans in 1991 to 219 million in 2011. This striking increase has paralleled increases in opioid overdoses and treatment for addiction to prescription painkillers.
  • An estimated 40% to 70% of Americans with chronic pain conditions do not receive proper medical treatment – meaning they are both over treated and undertreated with painkillers.

“We wanted to convey a number of messages with this report,” says report lead author David Reuben, MD, a geriatrician at the David Geffen School of Medicine at the University of California, Los Angeles. “First, we wanted to identify patients who could most benefit from opioids as well as those who could be most harmed by them. We also wanted to point out that data is limited and we need better studies to determine long-term safety risks” from these powerful painkillers, which include oxycodone, hydrocodone, morphine, methadone and others.

What the Panel Found

NIH Panel: A New Approach to Treating Pain with OpioidsThe NIH panel of seven experts came from various medical institutions nationwide and spent two days reviewing the latest evidence on the long-term effectiveness of opioids, safety concerns about the drugs’ risks and ways to minimize safety risks and maximize benefits for those suffering from chronic pain. “We found that some conditions are clearly responsive to opioids, particularly for short-term pain,” such as for relief following surgery, or for acute pain conditions that are temporary like kidney stones or a bone fracture after an injury, Dr. Reuben says.  Opioids also seem to work better in those with pain caused by cancer or rheumatoid arthritis, according to the evidence presented to the panel.

That said, for people with pain caused by a malfunction in the brain’s central nervous system – such as  fibromyalgia, irritable bowel syndrome, chronic tension headaches or jaw pain caused by temporal-mandibular joint (TMJ) disease — the relief isn’t as effective from an opioid, evidence suggests. Just how effective these painkillers are to manage persistent pain conditions in general isn’t clear, the panel concluded, due to a lack of long-term studies on the use of opioids beyond 12 weeks.

Who’s At Risk?

Certain people should not be prescribed opioids because they have a high risk of becoming addicted to them; this includes those with a history of drug dependency or alcohol abuse. Beyond that, “doctors can’t precisely predict who will likely become addicted to opioids and who won’t,” Reuben says.

Other possible dangerous side effects include mental confusion, slowed breathing and overdose death – OD deaths from these painkillers now account for more than 15,000 deaths each year in the U.S. – led Reuben and the rest of the expert panel to conclude that the drugs should be reserved as a last resort  for those with excruciating pain that can’t be managed with other medications or alternative therapies. “I do try to avoid prescribing opioids as much as possible in my own practice,” says Reuben. “I’ll prescribe non-steroidal anti-inflammatory (NSAID) drugs first, followed by cortisol injections or topical treatments like a lidocaine patch, which has an anesthetic.”

The establishment of clear guidelines to help doctors determine which pain medications to prescribe and for what conditions is vital, the panel stressed in its report, but certain barriers may still make any guidelines tough to actually implement. For one thing, physicians often lack the time and expertise to assess a patient’s pain, as well as how much someone’s discomfort has hurt their quality of life. Patients may lack access, too, to pain management specialists and other experts who can provide physical therapy and other rehab services to help them become more functional. And insurance plans may not cover integrative pain-management services such as massage therapy, acupuncture and other holistic therapies, the panel found. Some insurers don’t provide good coverage for effective non-opioid drugs , which often cost more than generic narcotics.

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