{"id":542,"date":"2015-01-22T16:00:11","date_gmt":"2015-01-22T16:00:11","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=542"},"modified":"2017-08-21T12:01:02","modified_gmt":"2017-08-21T12:01:02","slug":"primary-care-corner-with-geoffrey-modest-md-neurology-academy-recommendations-for-chronic-noncancer-pain-management","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2015\/01\/22\/primary-care-corner-with-geoffrey-modest-md-neurology-academy-recommendations-for-chronic-noncancer-pain-management\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Neurology academy recommendations for chronic noncancer pain management"},"content":{"rendered":"

By: Dr. Geoffrey Modest<\/strong><\/p>\n

The American Academy of Neurology published a position paper on the use of opioids for chronic noncancer pain, or CNCP, lasting more than 3 months\u00a0(see\u00a0doi:\u00a010.1212\/WNL.0000000000000839<\/strong>). Their basic argument is that there are no data showing that longer term opioids are effective (though they do acknowledge that none of the randomized controlled trials lasted more than a few months). a cross-sectional Danish study found\u00a0that those with chronic pain on opioids\u00a0reported that\u00a0over time they had\u00a0decreased pain relief, functional capacity and quality of life vs those not on opioids, “adjusting for severity” (I\u2019m not sure what that means. a little hard to imagine that they can really adjust for severity accurately in an observational study with the subjective endpoint of pain. and I would imagine a huge selection disadvantage if you look at those patients who had been put on opioids). the best intervention study I have found is a VA study looking at stable vs escalating doses of opioids for CNCP (see\u00a0doi:10.1016\/j.jpain.2010.09.003<\/strong>), which found that 135 patients already on opioids for pain relief and\u00a0referred to a pain clinic (94% male, 74% with musculoskeletal pain) were randomized to Stable dose vs Escalating dose of opioids, with escalation only if pain not adequately treated, at the discretion of the prescribing MD, and with no change in pill appearance. they\u00a0found that those in the Escalating dose group had no change in pain\u00a0or functional disability, but did have an improvement\u00a0in usual pain (nonsignificant) and\u00a0amount of relief (small but significantly decreased self-reported pain score with dose escalation)\u00a0but not with\u00a0the Oswestry disability index. And 27% were discharged from the study for\u00a0opioid misuse (no diff between the groups). BUT the Stable group went from 32 morphine-equivalent doses in the beginning of the study to 40 (not sure why??), whereas the Escalating dose group went\u00a0from 32 morphine-equivalents in the beginning of the study to only 50 at the end (i.e., not much of an escalation…).<\/p>\n

The neurol academy does\u00a0recommend the routine stuff: opioid treatment agreement, screen for prior\/current substance misuse, screen for depression\/anxiety\/PTSD, random urine toxicology screens, not use concomitant benzos, track pain and function (best with validated instrument), track morphine equivalent doses (MEDs), use state prescription drug monitoring program.<\/p>\n

But, in addition they recommend “avoid escalating doses above 80-120 mg\/d MEDs unless sustained meaningful improvement in pain and function is attained, and not without consultation with a pain management specialist”.<\/p>\n

There are a few very important unresolved and very confusing\u00a0issues for us chronic pain\u00a0prescribers.<\/p>\n

\u200b–we all (I suspect) have patients with noncancer chronic pain who have clinically clearly responded to higher doses of opiates and not to lower doses. And there are NO studies in the literature (that I know of) which have addressed this issue in an objective manner (i.e. RCT where patients have received significantly\u00a0increasing doses of opiates vs either placebo or stable low-dose opiates\u00a0and assessing pain\/disability\u00a0outcomes).<\/p>\n

–neurophysiologically (I believe) there is no difference between cancer and noncancer chronic pain. \u00a0They both trigger pain the same receptors. And it seems we need to treat pain in either case.<\/p>\n

–we do know reasonably well that increasing opiate dosages are associated with increasing substance use disorders and aberrant medication-taking behaviors (though, of note, in the VA study cited above, the opioid misuse was no different in those on escalating vs stable opioids). of major concern is\u00a0mortality associated with higher doses of opiates\u00a0(again, no RCT I am aware of, just the association, raising the issue that those patients requiring really high doses may have other reasons for increased mortality than the opiates). And there are other well-known adverse effects of opiates including hypogonadism\/infertility, falls\/fractures in elderly, neonatal abstinence syndrome, prolonged QTc with methadone, opioid-induced\u00a0hyperalgesia, etc.). In terms of mortality (but remember this is only observational data): one study found a 9-fold increase in overdoses in those on >100 morphine-equivalents vs those <20 and other studies have confirmed increased risk if above 80-120 MEDs.<\/p>\n

–we do know with certainty that prescribing opiates does have the unfortunate unintended consequence of being associated with diversion, with the (also well-documented) dramatic increase in prescription opiate addiction\/deaths in the community. The paper states that “over\u00a0100,000 people have died, directly or indirectly, from prescribed opioids in the US since the late 1990s”<\/p>\n

\u00a0\u200b–that all being said, I have had some, though limited success (based on the likely increased mortality with increasing opioid dosages) in dramatically\u00a0reducing the amount of morphine-equivalents in several patients, without significantly exacerbating the chronic pain<\/p>\n

So, what is one to do with the patient in front of you with disabling chronic pain refractory to other meds\/therapeutic modalities?? \u00a0the short answer is probably: treat the patient with opioids, trying to keep the dosages as low as possible, periodically trying to lower the dosages in those patients on high doses, consider\u00a0the advantages of other adjuvant therapies to keep the dose as low as possible (physical therapy, tricyclic antidepressants, other meds…), doing the appropriate screenings (urine tox screens, EKGs esp. for those on methadone, and others as recommended above)\u00a0and referring to pain clinics for their input on management of difficult, inadequately-responding\u00a0cases. As a primary care physician seeing many patients with chronic pain, I do not think there is an arbitrary cutoff of 80-120 morphine-equivalents as the neurology society recommends\u00a0(seems a bit self-serving to recommend referrals to themselves as a requirement…). Though in many difficult\u00a0cases a pain clinic referral can be helpful.<\/p>\n","protected":false},"excerpt":{"rendered":"

By: Dr. Geoffrey Modest The American Academy of Neurology published a position paper on the use of opioids for chronic noncancer pain, or CNCP, lasting more than 3 months\u00a0(see\u00a0doi:\u00a010.1212\/WNL.0000000000000839). Their basic argument is that there are no data showing that longer term opioids are effective (though they do acknowledge that none of the randomized controlled […]<\/p>\n

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