Should Neurologists Prescribe Opioids for the Management of Chronic Pain?

VBCN - May 2015 Volume 2, No 1

Washington, DC—Experts at the 2015 annual meeting of the American Academy of Neurology engaged in a series of debates addressing current issues in neuroscience. During one of the more controversial debates, Charles E. Argoff, MD, Professor of Neurology, Albany Medical College, Director of the Comprehensive Pain Center, Albany Medical Center, Albany, NY, advocated the benefits of prescription opioids for the treatment of patients with chronic pain, whereas Gary M. Franklin, MD, MPH, Research Professor, Departments of Occupational and Environmental Health Sciences, Neurology, and Health Services, University of Washington, Seattle, criticized the medical oversight that has led to a public health epidemic of opioid abuse.

Meaningful Relief of Chronic Pain

According to the 2011 Institute of Medicine report, “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” chronic pain affects approximately 100 million US adults. A neurologist’s goal for the management of chronic pain, Dr Argoff said, should be to define the most appropriate treatment regimen for each patient—that is, multimodal therapeutic strategies for pain and associated disability—which could include opioids.

“Most neurologists currently treat patients who, as a part and in the course of their neurological disorders, experience severe chronic pain,” said Dr Argoff, who listed more than 20 neurologic
diseases defined by this condition. “Pain management is an essential part of a neurologist’s training.”

While citing abundant evidence for the use of opioid analgesics for chronic neuropathic pain, Dr Argoff also stressed the importance of using the lowest necessary dose for safety reasons.

“All prescribers play an active role in reducing the risks associated with opioids,” said Dr Argoff. “When considering a chronic pain treatment plan, a neurologist should complete an appropriate risk assessment prior to prescribing, and they should monitor the patient regularly on an ongoing basis.”

Opioid analgesics are among the most frequently misused or abused pharmaceuticals; overdose deaths from prescription painkillers increased fourfold between 1999 and 2010. According to Dr Argoff, however, these numbers are on the decline, which is the direct result of improved guidelines in opioid prescribing practices.

“Many policy changes, such as the implementation of state prescription drug monitoring programs and screening for risk factors for misuse and abuse, have succeeded in making opioid therapy safer; misrepresenting opioid efficacy and erecting barriers to meaningful relief of chronic pain for your patients have not,” said Dr Argoff.

Dr Argoff also noted that neurologists routinely prescribe treatments that have serious risks associated with their use. “The question of whether a neurologist should prescribe opioids is a false dichotomy,” Dr Argoff concluded. “Not only should neurologists prescribe opioids for chronic pain, we must be well-prepared to prescribe opioids when appropriate for the best benefits to our patients while reducing the risks to the fullest extent possible.”

“Worst Man-Made Epidemic in Modern History”

Dr Franklin defended his position with respect to opioid analgesics.

“Because of the teachings that occurred in the late 1990s, we are now experiencing the worst man-made epidemic in modern medical history,” he began, before reciting the statistics attributed to opioid use: more than 140,000 deaths, hundreds of thousands of overdose admissions, millions of individuals addicted and/or dependent on opioids.

“We were taught originally that addiction was less than 1%,” said Dr Franklin. “But opioid use disorder is estimated in 29% of people on chronic opioids.” According to Dr Franklin, origins of the opioid use epidemic began with a lobbying effort largely funded by drug companies that changed more than 20 state laws.

“By the late 1990s, at least 20 states passed new laws, regulations, or policies moving from near prohibition of opioids to use without dosing guidance,” Dr Franklin explained.
Even after discounting the severe risks, which include mortality, overdose, dependence and addiction, and lifelong disability, Dr Franklin saw little benefit to opioid therapy––only diminishing effectiveness.

“You’re putting patients at risk,” said Dr Franklin, citing a study that demonstrated only modest pain improvement and functional improvement that was nonexistent with opioid use. “You might be improving their pain a little bit (30%), but you’re not improving their ability to do more every day.”

Efforts to improve opioid dosing guidelines in Dr Franklin’s home state of Washington have resulted in a 27% decline in overdose-related deaths, dramatically reducing the incidence rate of ongoing opioid use in the workers’ compensation system. “Opioids in our system are not only initiating but perpetuating disability among injured workers who are coming into the system with a low-back sprain,” said Dr Franklin. “I believe that we need to find ways to offer doctors, patients, and communities alternatives as part of the multimodal system of helping these patients with nonpharmacologic therapy for chronic pain.”

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