Goldilocks and the Opioids

July 12, 2019

Medical professionals don’t want to prescribe too many pain killers, which may contribute to the epidemic of opioid misuse, yet they don’t want patients to needlessly suffer.

Everyone knows the story of Goldilocks and her visit to the home of the three bears, where she was seeking the right balance between the things she discovers to attain the maximum comfort.

Medical professionals face something similar when it comes to prescribing opioids. We don’t want to prescribe too many pain killers, which may contribute to the epidemic of opioid misuse, yet we don’t want to have patients needlessly suffering who might benefit from opioids for pain management. Two recent publications highlight both the concerns regarding this issue and also the limitations in our knowledge regarding how best to achieve the ideal.

The first is a letter signed by over 300 medical professionals to the Centers for Disease Control and Prevention(CDC) regarding its guideline on prescribing opioids for chronic pain issued in 2016.1,2 The guideline strongly recommends limiting the use of opioids for the management of chronic pain, noting the lack of research to support their use for this and highlighting the potential benefits of using non-pharmacologic treatments and non-opioid medications.

Although the letter doesn’t dispute the CDC guideline recommendations, it expresses concerns that within a year of its publication, “there was evidence of widespread misapplication of some of the Guideline recommendations” including concerns about exceeding its recommended opioid daily dosage limitations.

According to the letter, the guideline has resulted in barriers to patients obtaining needed opioids including amount and dosage limitations set by insurance companies, limitations in dispensing the medications by pharmacies, and doctors themselves limiting or even refusing to prescribe opioids out of fear of legal action if they consider prescribing them in a manner that is different from what the guideline recommends. The letter also states:

Patients with chronic pain, who are stable and arguably benefiting from long-term opioids, face draconian and often involuntary rapid dose reductions. Furthermore, the guideline has created barriers that have resulted in not only unnecessary suffering because of patients being unable to obtain the opioids they require to control their pain but also other problems. In desperation, patients in pain are turning to suicide or illicit drug use or being forced to turn to invasive treatments such as spinal injections that often provide little benefit.

In the letter from the health professionals, they note, appropriately, that there is little objective evidence for their statements and that the letter is mostly based on anecdotes. In fact, the one point that the letter makes that anyone who does pain management can attest to without any doubt is that the non-medication treatments recommended by the CDC, which the letter doesn’t name but includes treatments such as cognitive-behavioral therapy and acupuncture, may not be covered by insurance thus limiting access to them.

The letter expresses concerns about the CDC guideline recommended maximum opioid daily dose of 90 morphine milligram equivalents per day-if clinicians believe a higher dose is required, they should “carefully justify a decision” to do this. (For a dose conversion table for other opioids, see www.cdc.gov/drugoverdose/pdf/caclulating_total_daily_dose-a.pdf.)

This recommendation that physicians should provide a clear justification for higher doses of opioids should not be a substantial obstacle, but a recent study showed that a pain diagnosis is lacking in over 28% of patients prescribed opioids. It appears that opioids are frequently prescribed without much thought whatsoever, much less careful thought.3

I am skeptical of several of the points included in the letter. I have read many anecdotes about patients started on opioids for legitimate pain complaints who, as a result of physicians reducing or discontinuing the medications, turned to illicit medications, ie, heroin or illicit fentanyl. However, for the most part, there was information in their stories that didn’t quite fit. Questions remained about whether there was a legitimate reason for prescribing the opioid in the first place and whether at least some of these patients were already suffering from opioid use disorder.

It is worth noting that even when the number of opioid prescriptions was increasing during the last decade of the 20th century and the first decade of the 21st, there was no apparent reduction in the number of unnecessary treatments such as spinal injections despite limited evidence of their efficacy. This suggests that whether opioids are liberally or conservatively prescribed has little to do with the frequency of the provision of such treatments.

The letter calls on the CDC to evaluate the impact its recommendations have on patients and caregivers and that it clarify its recommendations on opioid taper and discontinuation. I agree with the need for ongoing research about the effects of the CDC guideline, but I am troubled by what the letter ignores.

Although the letter indicates that physicians may have misread the guideline as being a requirement, I question how frequent this is. Considering the number of guidelines that have been issued for many different disorders and problems, I hope that health care professionals are aware that guidelines are not laws. As far as I’m aware none, including the CDC, require or expect that every patient be treated according to a specific guideline.

Based on my experience, I believe that most physicians who refuse to continue treatment with opioids or to initiate them based on the CDC guideline may be using it as an excuse, not a reason. It is far easier for physicians to say they are prevented from prescribing an opioid or are required to limit dosage or discontinue it, than to tell patients they (the prescribers) are making the decision. It may take considerable time and effort to explain to patients the reasons for the decision.

There are two other points that the letter overlooks. The first is the reasons why physicians may seek to reduce and possibly discontinue opioids. It is widely thought that the only reason for this is fear of addiction. It is true that this is a problem, and evidence has shown that a significant number of patients taking opioids for chronic pain end up misusing these medications. However, of equal importance is the issue of hyperalgesia where extended use of opioids can actually lower the pain threshold and thereby exacerbate the pain. Although the correct treatment for this is to reduce and discontinue the opioid, the worsening of the pain is often misinterpreted as being due to tolerance or worsening of the condition, which results in an increase rather than a decrease in the dose.

The second overlooked issue is how we should be evaluating the efficacy of opioids or any other treatment for chronic pain. From the letter it would be easy to conclude that measurement of the pain itself is of most importance. However, it is generally agreed that a far better measure of efficacy and one that can be more objectively observed than pain level is the level of functioning.

I have treated many patients with chronic pain over the course of my career with opioids and all have had one thing in common: there is evidence that they are functioning better because of the medications. When these patients are in a fairly stable condition, I try to reduce dosage and, if this is possible, to consider discontinuation. I have never just started a patient with chronic pain on an opioid and then not made an attempt to see if it is still required over time.

The letter calls on the CDC to clarify its recommendations on the tapering and discontinuation of opioids, and I believe this is appropriate. This is another area of pain management with limited research, which the CDC notes. We have very little guidance as to the best ways to taper doses of opioids either with the goal of reducing dosage or discontinuing the medications. A recently published statement calls attention to concerns over rapid and forced tapering for outpatients. This is something that seems to be more for the benefit of health care providers who no longer wish to prescribe opioids than of patients.4

Medication management of opioid use disorder: what we know and what we don’t

The National Academies of Sciences (NAS) recently issued a report on the use of medications for opioid use disorder that highlights the efficacy of the three currently available medications for the management of opioid use disorder: methadone, buprenorphine, and extended-release naltrexone. The report emphasizes the problem of the underutilization of these medications.5

I am in complete agreement but have one major problem with the report. There is virtually no attention given to the issue of iatrogenic opioid use disorder where patients are appropriately treated with opioids for a legitimate pain problem and end up misusing them.

The report briefly mentions the problem of opioid use disorder among patients with chronic pain. However, it primarily addresses the treatment of opioid use disorder in people with comorbid chronic pain, and it notes the limited research on the efficacy of medication treatment for opioid use disorder. However, there is no specific mention of iatrogenic opioid use disorder and what recommendations there are for its management or the need for future research.

Although the evidence for the existence of iatrogenic opioid use disorder goes back almost 30 years, we still know very little about it. We don’t know if either the physiology or psychology of it is the same or differs from opioid use disorder resulting from the non-medical use of opioids much less whether the treatment for both should be the same.

If methadone and buprenorphine are the appropriate treatment for iatrogenic opioid use disorder, they should also be the first-line treatments for pain because they are just as effective for pain management as other opioids. We would then have something unique in medicine: the same medications that cause the problem are also the appropriate treatment for it.

Why is iatrogenic opioid use disorder so ignored by the NAS report? I can’t be certain, but I believe that an important factor is those involved in writing the report. These are substance abuse experts who probably have limited experience with iatrogenic opioid use disorder and may not even be aware of it. The fact that substance abuse experts involved in the development of DSM-IV and DSM-5 failed to include a separate iatrogenic opioid use disorder diagnosis suggests that they may have limited knowledge about it or think it’s so incredibly rare that it doesn’t warrant a separate diagnosis.

I should note that the letter critical of the CDC guideline also suffers a similar shortcoming. The primary authors of the letter appear to be experts in substance abuse but not in pain management. Many of the over 300 who endorsed the letter are pain specialists and many are addiction specialists, but there are very few who can be considered experts in both and might be expected to be better able to weigh the risks and benefits of opioids.

We need doctors who have training in pain management and addiction medicine. Patients who appear to be receiving only limited benefit from opioids still often refuse to discontinue them out of fear that they will be left to suffer even more than they already are. Patients need to be taught other methods for managing pain apart from opioids for there to be any reasonable expectations that they will agree to reduce the dose or discontinue use.

There are two ways we can address the lack of doctors with expertise in pain management and opioid misuse. Because pain management falls under anesthesiology in most medical schools and hospitals, we could require that anesthesiologists receive training in recognizing and managing substance abuse. Conversely, substance abuse primarily falls under psychiatry, but most psychiatrists receive limited training in pain management.

Although it is doubtful that anesthesiology programs will ever provide much training on substance abuse, I still hope that psychiatry will recognize the important role it can play in pain management. Someone with training in both pain management and substance abuse would be better able to weigh both the benefits and risks associated with the use of opioids in patients with chronic pain and tailor treatment to the needs of individual patients.

Disclosures:

Dr King is in private practice in Philadelphia.

References:

1. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain: US, 2016. MMWR. 2016;65:1-49.

2. Health Professionals for Patients in Pain. Professionals call on the CDC to address misapplication of its guideline on opioids for chronic pain through public clarification and impact evaluation. March 6, 2019. http://www.healthprofessionalsforpatientsinpain.org. Accessed May 12, 2019.

3. Sherry TB, Sabety A. Maestas N. Documented pain diagnoses in adults prescribed opioids: results from the National Ambulatory Medical Care Survey, 2006-2015. Ann Intern Med. 2018;169:892-894.

4. Darnall BD, Jurrlink D, Kerns RD, et al. International stakeholder community of pain experts and leaders call for an urgent action on forced opioid tapering. Pain Medicine. 2019;20:429-433.

5. National Academies of Sciences, Engineering, and Medicine. Medications for Opioid Use Disorder Saves Lives. Washington, DC: The National Academies Press; 2019.

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