Little research evidence exists to support either the most widely used prescription opioid treatments for chronic pain or the alternative treatments that exist, according to an independent panel convened by the National Institutes of Health (NIH). Moreover, the healthcare system has not encouraged the kind of patient-centered, team-based treatment approaches that could improve outcomes for chronic pain patients, which has left individual physicians with little guidance for treatment decision-making.
“At almost every step of the process, from patient identification, to deciding which drugs to use, to deciding what is the proper dosing, to making changes in prescriptions, there is very little data to guide practice,” panel member Anika A.H. Alvanzo, MD, medical director of the Substance Use Disorders Consultation Service at Johns Hopkins University School of Medicine, told Addiction Professional prior to a Jan. 16 panel media briefing on its findings. The panel report was released in full last week and also was published in summary form in the Annals of Internal Medicine.
The report grew out of a two-day NIH Pathways to Prevention workshop held last September on “The Role of Opioids in the Treatment of Chronic Pain,” at which the seven-member panel representing numerous branches of medicine assessed existing evidence about pain treatment and heard testimony from healthcare experts and the public. Overall, the report paints a bleak picture of current chronic pain treatment, stating that there are clearly many more patients who would benefit from alternatives to long-term opioid use than would find opioids to be their ideal treatment. The independent report does not represent an official position statement for the NIH.
Panel member David C. Steffens, MD, chairman of the Department of Psychiatry at the University of Connecticut Health Center, referred in last week's media briefing to “an astounding lack of data on efficacy” of widely used pain treatments. Many leaders in the addiction treatment community point to overprescribing of potent opioids as greatly responsible for the rise in opioid dependence and overdose in recent years. The Centers for Disease Control and Prevention reports that treatment admissions for addiction to prescription opioids increased fourfold from 2000-2010.
But panel members also point out that alternative treatments have not built a strong evidence base either, and undertreatment of pain (often accompanied by stigmatization of pain patients) remain critical problems in healthcare.
The areas where pain management and opioid dependence intersect will be a major focus of next month's Addiction Professional Academy conference in Orange County, Calif., produced by the publishers of Addiction Professional and to be held Feb. 2-4.
Barriers to effective care
Prior to the September workshop, the Pacific Northwest Evidence-Based Practice Center completed for the panel a literature review on the long-term effectiveness of opioids as well as the effects of opioid management and risk mitigation strategies. The panel would find, based on this review and on testimony heard at the workshop, that a general lack of empirical evidence makes it difficult to draw firm conclusions in these areas.
Alvanzo did say in the media briefing that the healthcare community is gradually gaining an understanding, for example, of possible patient risk factors for prescription opioid dependence (such as a prior substance use disorder or a co-existing mood or anxiety disorder). In addition, there is emerging evidence that certain central pain syndromes, such as fibromyalgia, generally do not respond as well to opioids as pain caused by tissue damage or inflammation.
Several workshop presenters advocated a multidisciplinary approach to pain management that might include primary care physicians, nurses, pharmacists, behavioral health specialists and social workers. Yet the report states that “management of chronic pain has been largely relegated to the primary care providers working in health systems not designed or equipped for chronic pain management.” And with much of physicians' work now expected to be executed in brief office visits, quick processes such as the writing of a script “have become the default option,” the report states.
Alvanzo said in her comments to Addiction Professional that payers will have to play a role in solving this dilemma. “The current reimbursement structure, whether intentional or not, promotes the use of opioids,” she says.
The report points out that higher-volume prescriptions of longer duration are seen in the healthcare system as reducing administrative costs, even though this approach to prescribing exacerbates potential risk of adverse events.
Several panelists said in the media briefing that the workshop testimony they received from patients and patient advocates amounted to some of the most powerful comments they heard, serving as a warning that over-regulation of opioids could become as problematic as over-prescription has been. Steffens said that for patients who complained of undertreatment of pain, there often had been a feeling of being branded as a medication-seeker or criminal from both the medical and pharmacy communities.
The panel report issues nine recommendations designed to address the scarcity of available data on long-term opioid treatment, patient assessment, dosing strategy, and risk mitigation. These are some of the key recommendations:
Federal and non-federal agencies should sponsor research to identify which types of pain, illnesses, and patients are most likely to benefit from or be harmed by opioids.
These agencies also should sponsor development and evaluation of multidisciplinary pain interventions, including cost-benefit analyses.
Agencies should add to the scant research base evaluating opioid treatment risk mitigation strategies such as urine drug screening, patient agreements, and prescription drug monitoring programs (PDMPs) that have been initiated by many state governments.
“In the absence of definitive evidence, clinicians and health care systems should follow current guidelines by professional societies about which patients and which types of pain should be treated with opioids, and about how best to monitor patients and mitigate risk for harm,” the report states.
Sign of a turnaround?
On the same week that the NIH-commissioned panel issued its report, a nonprofit prescription drug abuse surveillance system published trend data for six prescription opioids (including oxycodone and hydrocodone), showing abuse rates starting to decline from 2011-2013.
The report, “Trends in Opioid Analgesic Abuse and Mortality in the United States,” was featured in the New England Journal of Medicine. It did cite evidence, however, that heroin-related deaths tend to increase as prescription drug abuse declines, and suggests that this phenomenon needs to be investigated more closely in order to shape sound prevention and treatment strategies.