The striking lack of data on the effectiveness and risks of long-term opioid treatment for the increasing number of people in the United States with chronic pain is reflected in the recommendations made by an expert panel convened by the National Institutes of Health.
To address the role of opioids in the treatment of chronic pain, the panelists met during an NIH Pathways to Prevention workshop in late September where more than 20 invited experts spoke on the topic. The panel produced a draft report shortly after the meeting concluded and received public comments, and the final report has been published on the NIH website. An abridged version of the panel’s final report, which highlights key issues surrounding the use of opioids and chronic pain treatment and provides recommendations on the types of research needed in this area, was published online Jan. 13 in the Annals of Internal Medicine ( doi:10.7326/M14-2775 ).
“The overriding question posed to the panel is whether we as a nation are currently approaching chronic pain in the best possible manner that maximizes effectiveness and minimizes harm. The panel determined that the answer was an unequivocal no,” Dr. David Reuben, the panel chair and lead author of the report, said during a Jan. 16 telebriefing that was held to review the panel’s findings and recommendations. “We hope that the information presented in the panel report will shed light on the issues that need further attention and help facilitate research and better practice to improve outcomes for patients,” added Dr. Reuben, who is chief of geriatric medicine and professor of medicine at the University of California, Los Angeles.
The first recommendation in the panel’s position paper is that federal and non-federal agencies should fund research to identify what types of pain, diseases, and patients “are most likely to benefit and incur harm” from opioids. Agencies should also fund the development and evaluation of multi-disciplinary pain interventions, including cost-benefit analyses, and fund research to “develop and validate research measurement tools” that identify patient risk and outcomes, “related to long-term opioid use that can be adapted for clinical settings,” the panel recommended.
The one recommendation that directly pertains to current clinical practice states that “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.” In addition, the report “identifies several key evidence gaps and research priorities that must be addressed so that physicians can recognize patients for whom opioids are most appropriate and use optimal regimens for these patients.”
Considering professional society guidelines is one of the main take home-messages of the report for clinicians, Dr. David Steffens, another panelist and author of the paper, said during the telebriefing. Dr. Steffens, professor and chair of the department of psychiatry, University of Connecticut, Farmington, observed that during the workshop, “the core part of what we heard was an astounding lack of data on efficacy of these drugs,” and noted that the majority of recommendations are “forward-looking in terms of a need to get more data.”
Among the main conclusions of the position paper is that while opioids are “clearly the best treatment for some patients with chronic pain … there are probably more effective approaches” for many other patients. “The challenge is to identify the conditions in patients for which opioid use is most appropriate, the optimal regimens, the alternatives for those who are unlikely to benefit from opioids, and the best approach to ensuring that every patient’s needs are met by a patient-centered health care system,” the report concludes.
A systematic review of the effectiveness and risks of long-term opioids for chronic pain, prepared specifically for the workshop by the Pacific Northwest Evidence-based Practice Center (EPC) at Oregon Health & Science University, Portland, with funding by the Agency for Healthcare Research and Quality , was also published in the same issue of Annals of Internal Medicine ( doi:10.7326/M14-2559 ). The review, which evaluated evidence in the medical literature about the effectiveness and risks of long-term opioid therapy (more than 3 months) to treat chronic pain in adults, concluded that “reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date.” Moreover, evidence indicating that long-term opioid therapy is associated with significant risks for overdoses, abuse, and other sequelae is increasing, according to the review, which defines chronic pain as pain “lasting longer than 3 months or past the normal time for tissue healing.” Dr. Roger Chou, director of the Pacific Northwest EPC and a physician in the OHSU internal medicine clinic, was the lead author of the review.
An estimated 100 million Americans have chronic pain, of whom about 25 million have moderate-to-severe pain that limits activities and adversely affects their quality of life, according to the position paper. Despite other available treatments, opioids are used for long-term management of chronic pain in an estimated 5-8 million Americans and prescriptions for opioids to treat pain increased from 76 million in 1991 to 219 million in 2011. This increase has been accompanied by a rise in opioid overdoses and treatment for addictions to prescription pain medications. The paper cites Centers for Disease Control and Prevention figures estimating that in 2011, there were more than 17,000 opioid-related overdose deaths.
The NIH Pathways to Prevention Workshop was sponsored by the NIH Office of Disease Prevention, the NIH Pain Consortium, the National Institute on Drug Abuse, and the National Institute of Neurological Disorders and Stroke.
None of the authors of the report had disclosures relevant to the topic. Dr. Chou’s disclosures included having received grants from the AHRQ during the study. He has also been a consultant for the U.S. Department of Health and Human Services and the Providers’ Clinical Support System for Opioid Therapies, which is funded by the Substance Abuse and Mental Health Services Administration.
