A TEAM APPROACH TO PAIN MANAGEMENT
Neurologists interviewed by Neurology Today about the CDC report said it is encouraging that opioid prescribing seems on the downturn, but they said the overall picture remains bleak.
“Even though prescribing rates are coming down, death rates (from opioids) are still going up,” said Gary M. Franklin, MD, FAAN, research professor for the departments of environmental health, neurology and health services at the University of Washington, and the author of an AAN position paper on opioids for chronic noncancer pain published in Neurology in 2014.
“You can't take this report to mean we are doing great. We are doing a little bit better,” he said
Dr. Franklin, who is medical director for the Washington State Department of Labor and Industries, believes that opioids should only be prescribed in rare instances, noting that physical dependence and addictive tendencies may develop in a matter of weeks. He said that opioids are not appropriate for treating chronic headache and chronic back pain and seem to be of little help for polyneuropathy. He favors a team approach to treating pain that connects patients with other complementary approaches, such as cognitive behavioral therapy, and treatment of comorbid conditions, such as depression and anxiety.
“We should be doing a better job of providing multimodal, collaborative care for pain,” Dr. Franklin said.
PAIN TREATMENT CAN'T BE IGNORED
Several neurologists interviewed by Neurology Today expressed concern that the growing wariness about opioids could have the unintended consequence of leaving pain patients without adequate relief. They also said more research is needed to identify effective alternatives for treating pain, including development of non-addictive pain relievers.
“There are people who actually need opioids to manage their pain,” said Howard L. Fields, MD, PhD, FAAN, professor of neurology and director of the Wheeler Center for the Neurobiology of Addiction at the University of California, San Francisco (UCSF).
Dr. Fields said he agreed with the CDC's guidelines aimed at reducing prescription opioids for chronic pain, but he is concerned that the recommendations may have led to over-cautiousness in instances when an opioid drug may be warranted. It is important to keep in mind that the opioid epidemic gripping the country is caused by multiple and complex factors, Dr. Fields said.
Dr. Fields is doing research into the neurobiology of addiction and is working on ways to modify molecules in opioid painkillers so “that we can improve the desirable characteristics and reduce the adverse characteristics.”
PAIN DIAGNOSIS AND TREATMENT
Peter L. Jacobson, MD, FAAN, professor of neurology at the University of North Carolina (UNC) School of Medicine and director of the UNC neurology palliative care program, said effective pain management begins with making the right diagnosis, which requires taking the time to do thorough neurologic examination to identify the source or sources of the pain. He said establishing a rapport with the patient helps with getting a detailed medical and social history to determine if there are contributing factors such as depression or post-traumatic stress that need to be addressed as part of the treatment plan.
“We have an ethical duty to address pain and suffering,” said Dr. Jacobson, but in most situations there are effective alternatives to opioids, including non-steroidal anti-inflammatory drugs for arthritis and chronic post-traumatic cervical and lumbar pain, as well as triptans and prophylactic medications (such as propranolol, and amitryptyline) for migraine headaches. Chronic neuropathic pain can be treated with nerve blocks, gabapentin, pregabalin, and duloxetine, he said. Massage, exercise, meditation, and physical therapy can also be helpful for pain, he said.
Dr. Jacobson said that if opioids are prescribed, an informed consent form should be used to detail proper use and risks. Among those risks are a prior history of drug or alcohol abuse, a family history of drug or alcohol abuse, and a history of mood or anxiety disorders, among others.
If a patient's history reveals concerns about addiction, the patients should be referred to an addiction specialist, he said.
“Our job as neurologists treating pain is to avoid opioid diversion and prevent opioid addiction. We refer the patient to addiction specialists and programs to safely detox and treat an addict who is taking dangerous amounts of medication,” he said.
Miroslav “Misha” Backonja, MD, emeritus professor of neurology at the University of Wisconsin and clinical professor of neurology at the University of Washington, said it is not surprising that prescribing practices of opioids vary, given that many of today's physicians have experienced ever-changing views related to its use — from a time when opioids were rarely prescribed, to when they were seen as having an important role in pain management, to today when “there is a runaway train of overuse.”
Dr. Backonja works from the starting point that there is rarely an indication for opioids as a first-line therapy for chronic pain, but that is when his work begins. “So if not opioids, then what?” he said. “I never view my patients from the perspective of suspicion but rather from the perspective of the need to treat their pain. Every patient needs to receive an accurate pain diagnosis and be provided a specific therapy as available.”
He said the treatment of neuropathic pain can be challenging, for example, because there is no one treatment that is the gold standard.
“We have options but they are far from perfect or even adequate,” said Dr. Backonja, who also is senior medical director for Worldwide Clinical Trials, which oversees the testing of new drugs in development. He said combination therapies, including non-medicinal ones, are usually the best approach for pain management.
While reducing the use of unnecessary opioid prescribing should continue to be a top priority in public health, so, too, should be finding better and safer alternatives for pain relief, said Dr. Backonja. “We still have plenty of pain that needs to be addressed.”
CDC REPORT AND RECOMMENDATIONS
The CDC analysis is based on data from the QuintilesIMS Transactional Data Warehouse, which provides estimates of the number of opioid prescriptions dispensed in the United States based on a sample of about 59,000 pharmacies. Researchers looked at changes in prescribing from 2006 to 2015 both nationally and at the county level.
“Annual opioid rates increased from 72 to 81.2 per 100 persons from 2006 to 2010, were continuous from 2010 to 2012, and then decreased by 13 percent to 70.6 per 100 persons from 2012 to 2015,” the MMRW report said. The amount of opioids prescribed peaked at 782 morphine milligram equivalents (MME) per capita in 2010 and then decreased to 640 MME per capita in 2015.
At the same time, “The average duration of opioid prescriptions increased, in part because of the continued increase in longer opioid prescriptions (greater or equal to 30 days) through 2012, followed by a stabilization of the rate, and a substantial decrease in shorter prescriptions (less than 30 days) after 2012,” the report said. The average supply of opioids prescribed increased from 13.3 days in 2006 to 17.1 in 2015.
The CDC report found great variation in prescribing practices at the county level. The top-prescribing counties had six times as much opioid prescribing as the lowest prescribing counties in 2015. Higher amounts of opioids were prescribed in counties with a larger percentage of non-Hispanic whites; a higher prevalence of diabetes and arthritis; more small towns or rural communities; and higher rates of unemployment and Medicaid enrollment. The county variations suggest not only that socioeconomic factors are at work in the opioid epidemic, but that there are wide differences in the prescribing practices of physicians who treat patients for pain.
The report cited prior research showing patients are unlikely to discontinue opioids if they have received them for 90 days.
The report issues these recommendations for prescribing physicians:
- Use opioids only when benefits are likely to outweigh risks,
- Start with the lowest effective dose of immediate-release opioids. For acute pain, prescribe only the number if days that the pain is expected to be severe enough to require opioids
- Reassess benefits and risks if considering dose increases.
- Use state-based prescription drug monitoring programs, which help identify patients at risk for addiction or overdosing.
RESEARCH RECOMMENDATIONS FROM THE NATIONAL ACADEMIES OF SCIENCE, ENGINEERING, AND MEDICINE
The release of the study on prescribing trends came just ahead of a two-day meeting of experts assembled by the US Food and Drug Administration (FDA) to consider ways to further reduce the misuse and abuse of prescription opioids. FDA Commissioner Scott Gottlieb announced plans to require drug manufacturers to provide more training on proper prescribing practices to doctors and other health care providers.
The FDA meeting coincided with the release of a major report by the National Academies of Sciences, Engineering, and Medicine on July 13 that outlines strategies to help curb the opioid epidemic while making sure patients have access to a broad array of therapies for pain management. The report said the FDA should incorporate “public health considerations” into opioid-related regulatory decisions, rather than taking its usual product-specific approach for evaluating the merits of a new drug.
The reports made these among other recommendations:
- Improve the understanding of the neurobiology of pain.
- Develop evidence on promising pain modalities and support the discovery of innovative treatments, including nonaddictive analgesics and nonpharmacologic approaches.
- Improve the understanding of the intersection between pain and opioid use disorder.
PHYSICIAN TRAINING RESOURCES ON OPIOID PRESCRIBING
- The AAN offers webinars and CME online in management of chronic pain and opioids: https://tools.aan.com/education/webcme/
- In New York State, prescribers licensed under Title Eight of the Education Law in New York to treat humans and who have a DEA registration number to prescribe controlled substances, as well as medical residents who prescribe controlled substances under a facility DEA registration number, must complete at least three hours of course work or training in pain management, palliative care, and addiction. http://bit.ly/2NYS-opioidtraining
LINK UP FOR MORE INFORMATION:
•. Guy GP Jr., Zhang K, Bohm MK, et al Vital signs: Changes in opioid prescribing in the United States, 2006-2015 http://www.cdc.gov
/mmwr/volumes/66/wr/mm6626a4.htm. MMWR Morb Mortal Wkly Rep
2017; 66(26): 697–704.
•. Schuchat A, Houry D, Guy GP Jr., et al Viewpoint: New data on opioid use and prescribing in the United States http://jamanetwork.com/journals/jama/fullarticle/2643332. JAMA
2017; Epub 2017 Jul 6.
•. Pain Management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription overdose: A report of the National Academies of Sciences, Engineering, Medicine. http://www.nationalacademies.org
•. Franklin GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology http://http://www.neurology.org
© 2017 American Academy of Neurology
•. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain — United States, 2016 http://www.cdc.gov
/mmwr/volumes/65/rr/rr6501e1.htm. MMWR Recomm Rep
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