Physician's Weekly ER Edition Article - Clarifying Use of Opioid Therapy for Pain Management

       Physicians are being urged to approach long-term opioid therapy for pain in a way that incorporates a more balanced perspective of risks and benefits of these medications. The American Pain Foundation is encouraging greater collaboration and consensus about opioid use.

      According to the American Pain Foundation (APF), about 76.5 million American adults reported that they had a problem with pain which persisted for more than 24 hours in the past month. Additionally, more than half of all older adults who reported pain indicated that the pain lasted for more than 1 year. Opioids are highly effective analgesics that are well accepted as the mainstay treatment for some types of pain. However, their role in the long-term management of chronic non-cancer pain remains controversial.

      “Opioids are challenging medications because they’re the most effective medicines for acute and chronic pain, but they also have the potential for significant liabilities,” explains Russell K. Portenoy, MD. “They are widely considered the first-line drugs for the treatment of acute severe pain, and consensus statements endorse their use as first-line therapy for patients with pain from metastatic cancer, advanced HIV, and advanced illnesses of other types. However, there currently isn’t a consensus about the role of opioids in the treatment of highly prevalent, chronic non-cancer pain syndromes such as low back pain, joint pain, and headache.”

      Fears Being Fueled

      Studies have confirmed a dramatic rise in prescription drug abuse during the past 10 years. This has highlighted the inherent risks of using potentially abusable drugs for clinical purposes, and has also fueled fears and misunderstandings about potential risks for abuse, addiction, or diversion (Table 1). Dr. Portenoy says “clinicians need skills in risk assessment and management to overcome misconceptions and to provide opioid therapy to those who might benefit. If these skills are applied, concerns about oversights from regulatory and law enforcement agencies are minimized and the drugs can be administered in a way that optimizes benefit and minimizes risk. Unfortunately, many physicians lack the training needed to appropriately evaluate candidates for long-term opioid therapy, initiate and adjust therapy; and to recognize signs that are suggestive of addictive disorders. This contributes to a fear of regulatory scrutiny and may lead to inappropriate reluctance to try opioids.”

      Reviewing Barriers, Identifying Solutions

      The APF recently convened a roundtable of leading pain experts that led to the release of Provider Prescribing Patterns and Perceptions: Identifying Solutions to Build Consensus on Opioid Use in Pain Management. The document reviews the challenges surrounding optimal opioid therapy and pain management, and was intended to help inform clinicians and the public about appropriate opioid use. “The APF’s document provides recommendations for physicians and issues an urgent call to the pain community to reframe the discussion about opioid therapy in a way that incorporates a more balanced perspective of the risks and benefits of these medications,” explains Dr. Portenoy (Table 2). “Engaging and collaborating with health professionals, consumers, the pharmaceutical industry, law enforcement and regulatory agencies, and health policymakers is vital to establish a framework that supports better understanding of the issues surrounding opioid use.”

      Dr. Portenoy says there are clinical competencies that act as the foundation for this perspective in practice. “Careful patient selection and monitoring are essential for the safe and effective use of opioids over time. Two skill sets are required; the first is an ability to optimize the pharmacologic outcomes of opioid therapy, and the second is to assess and manage risk. To appropriately optimize therapy, clinicians must select an appropriate drug, titrate doses, treat side effects, and monitor analgesia and side effects. To assess and manage risk, therapy must be structured so that the extent of physician control and monitoring is commensurate with the perceived risk that patients may engage in problematic behaviors. Knowing how to structure therapy, monitor drug-related behavior, and deal with problematic behaviors when they occur are essential for moving opioid therapy into a broader population of chronic pain patients who could benefit from it.”

      Achieve Balance at the Bedside

      The APF emphasizes that more attention needs to be paid to the epidemic of chronic pain, its undertreatment, and the utility of opioid therapy as a strategy to relieve pain and improve functioning in appropriately selected and monitored patients. “Physicians need to strive for balance at the bedside,” says Dr. Portenoy, “meaning that clinicians need to feel empowered to use opioids as a potential tool for the treatment of chronic pain with the understanding and skills to select patients carefully and undertake therapies that incorporate risk assessment and management. Balancing the need to make opioid therapy available to medically appropriate patients with techniques to reduce potential risks is essential to reducing fears and misunderstanding and to improving patient access to a treatment approach that has great potential for some.”

      Russell K. Portenoy, MD, has indicated to Physician’s Weekly that he has consulted for Abbott Laboratories, Bayer Corporation, Biovail Pharmaceuticals, Cephalon, Cytogel, Endo Pharmaceuticals, Eurand, Forest Laboratories, GlaxoSmithKline, Janssen, King Pharmaceuticals, Ligand Pharmaceuticals, Merck & Co., Mylan Technologies, Neuromed Pharmaceuticals, Ortho-McNeil, PainCeptor, Pfizer, Pharmos, Sarentis Therapeutics, WEX Pharmaceuticals, and Xenon Pharmaceuticals.