NIH. US: The term “silent epidemic” sometimes gets overused in medicine. But,
for prescription opioid drugs, the term fits disturbingly well. In 2012,
more than 259 million prescriptions were written in the United States
for Vicodin, OxyContin, and other opioid painkillers. That equals one
bottle of pain pills for every U.S. adult. And here’s an even more
distressing statistic: in 2011, overdoses of prescription painkillers,
most unintentional, claimed the lives about 17,000 Americans—46 people a
day [1].
The issue isn’t whether opioid painkillers have a role in managing
chronic pain, such as that caused by cancer or severe injuries. They do.
What’s been lacking is an unbiased review of the scientific literature
to examine evidence on the safety of long-term prescription opioid use
and the impact of such use on patients’ pain, function, and quality of
life. The NIH Office of Disease Prevention (ODP) recently convened an
independent panel to conduct such a review, and what it found is
eye-opening. People with chronic pain have often been lumped into a
single category and treated with generalized approaches, even though
very little scientific evidence exists to support this practice.
Based on its review of the literature and
scientific research presented at the workshop, the seven-member panel
concluded that chronic pain spans a multitude of conditions, presents in
different ways, and requires an individualized, evidence-based approach
to manage. The workshop was convened by ODP, the NIH Pain Consortium,
the National Institute on Drug Abuse (NIDA), and the National Institute
of Neurological Disorders and Stroke (NINDS).
Such individualization won’t be easy to achieve. Data were presented
showing that people with peripheral pain, caused by tissue damage or
inflammation, may respond better to opioids than other types of
painkillers. This group includes people with cancer pain, rheumatoid
arthritis, and severe pain due to injury. On the other hand, people with
central pain syndromes, characterized by disturbances in the processing
of pain by the brain and spinal cord, may respond better to
antidepressants and anticonvulsants than to opioids. Such syndromes
include fibromyalgia, irritable bowel syndrome, temporomandibular joint
disorder, and tension headache. To add to the complexity, some workshop
attendees cautioned against making sweeping statements about which types
of patients are—and are not—most likely to benefit from prescription
opioids.
The panel’s report, a summary of which was just published in the Annals of Internal Medicine
[2], contains many other valuable insights. For example, I was deeply
troubled by how little scientific evidence exists to support the safety
and efficacy of long-term opioid use; most clinical studies on opioids
and chronic pain have lasted 6 weeks or less. That is a serious
knowledge gap, especially in light of the fact that up to 8 million
Americans use opioids for long-term pain management—and the known side
effects of short-term opioid use include nausea, mental clouding, and
respiratory depression, along with overdose. Until more scientific
evidence is generated on the effects of long-term opioid use, the panel
suggests that people seeking help for chronic pain be initially
encouraged to try non-drug approaches, such as physical or behavioral
therapy. If such approaches fail to ease the pain, potentially riskier
drug options, including non-opioid and opioid medications, could then be
explored—but with great care.
As is increasingly the case for all areas of medicine, the panel
concluded that the best pain management strategy is one tailored to
identify and meet a patient’s individual needs. Taking this point a step
further, the panel recommended that initial patient evaluations go
beyond a standardized pain assessment (On a scale of 1 to 10, what is
your pain level?) to consider more fully the whole patient—from quality
of life and psychological wellbeing to the presence of other
pain-causing conditions and sensitivity to pain.
A lot of this may be easier said than done. The expert panel
acknowledged that, in the real world, many healthcare providers
currently do not have the time or the tools to conduct such detailed
evaluations, and some health insurers do not cover non-drug
interventions or non-opioid drugs as first-line treatments for chronic
pain. Furthermore, once a healthcare provider has prescribed an opioid
drug to a patient with chronic pain, there are insufficient data on drug
characteristics, dosing strategies, or tapering to guide clinical care
effectively.
Clearly, NIH can’t address all of these challenges alone. However, we
are taking very seriously the panel’s call for more research to
generate the evidence-based, multidisciplinary approaches needed to
bring safe and effective relief to the millions of Americans living with
chronic pain.
The NIH is also doing everything it can to use the power of science
to reduce the very serious public health problem of the abuse of opioid
painkillers and other prescription drugs. In fact, on April 7, I’m
scheduled to be among the NIH scientists presenting at The National Rx
Drug Abuse Summit, which is a collaboration of professionals from
government, business, academia, clinicians, treatment providers,
counselors, educators, and advocates who are deeply concerned about
prescription drug abuse.
References:
[1] Vital Signs: Opioid Painkiller Prescribing, Centers for Disease Control and Prevention, July 2014.
[2] National Institutes of Health Pathways to Prevention Workshop: The Role of Opioids in the Treatment of Chronic Pain. Reuben DB, Alvanzo AAH, Ashikaga T, Bogat A, Callahan CM, Ruffing V, and Steffens DC. Annals of Internal Medicine. 2015 January 13.