The risk of death, overdose, addiction and serious side effects of opioids outweigh their pain relieving benefits in chronic non-cancer conditions, such as headache, fibromyalgia and chronic lower back pain, the American Academy of Neurology says in a paper published in Neurology
(online, 30 September 2014).
More than 100,000 people have died in the United States from prescribed opioids, directly or indirectly, since the 1990s when the drugs started to be used more widely for non-cancer chronic pain, the paper says. In the highest-risk group (35-54 years), mortality rates exceed those of both motor accidents and incidents with firearms.
The paper says studies have shown that half of patients taking opioids for at least three months are still taking them five years later and, while opioids may provide significant short-term pain relief, the evidence suggests they do not maintain pain relief or improved function over long periods of time without serious risk of overdose, dependence or addiction.
The academy recommends that both the patient and the prescriber sign an opioid treatment agreement at the outset of treatment and then annually, which outlines the risks of chronic opioid use and the responsibilities of the patient.
Before chronic therapy is started, patients should be screened for current or past drug abuse (illicit drugs, alcohol and heavy tobacco use), depression and anxiety. Urine should be tested for drugs and this testing repeated intermittently.
At every doctor’s visit, the daily morphine equivalent dose – and the patient’s pain and function – should be recorded to monitor the effectiveness of the opioids and any indication of the development of tolerance.
Dosages of 80-120mg/day MED (morphine-equivalent dose) should be avoided and those taking such a dose should be sent to a pain management specialist, especially if their pain and function have not substantially improved. “Opioid therapy should be only part of a multifaceted approach to pain management,” the academy emphasises.
Roger Knaggs, a member of the British Pain Society council, is unsure whether the UK faces similar problems of opioid misuse.
“Like in the United States, there has been a significant increase in opioid prescribing for pain in the UK and other European countries,” he says. “However, it remains unclear as to whether the harms and public health consequences of this increased prescribing are the same [as in the United States].” This uncertainty is partly because the UK has fewer data sources on opioid misuse, so it is difficult to obtain a clear picture of the situation
“The British Pain Society, in collaboration with other royal colleges, published good practice guidance for opioid prescribing in 2010 and this is being updated at present,” Knaggs adds.
The 2010 guidance says that patients with depression or anxiety will need additional support, and that patients with a history of addiction or 180mg/day MED should be referred to a specialist in pain management.