Chronic Pain—the Humane Use of Opioids
Some physician prescribers misread CDC guidelines.
This blog was published earlier today in a slightly different form in Psychology Today.
The contribution of prescribed opioids to the national opioid crisis (which includes non-prescribed drugs like heroin and cocaine) has been well described. Concern with the role these legal drugs play in addiction and overdose led the Centers for Disease Control and Prevention (CDC) to issue guidelines in 2016 that have been effective in reducing prescriptions for opioids.1 Emphasizing that there is no proven, long-term benefit of opioids for chronic pain, the CDC outlined recommendations for reducing opioid use.
Ragesoss — A neglected old boot
Unhappily, some clinicians’ misinterpretations flouted the guidelines. This created major distress for patients, a problem articulated by a prestigious consensus panel,2 and reviewed by the authors of the CDC guidelines in a recent New England Journal of Medicine article.3
For example, some physicians adhered to the guidelines with an inflexibility that created new health problems. By abruptly reducing and discontinuing opioid doses, or even refusing to prescribe them, patients who had developed opioid dependence suffered from sudden withdrawal, while some patients were dismissed from a practice altogether, left to treat their addiction on their own. As well, guidelines were erroneously applied to patients for whom they were not intended: those with cancer, sickle cell disease, and surgical procedures; and they were misapplied to patients with the severe form of opioid addiction called opioid use disorder.
The result was that many patients experienced withdrawal, increased pain, inability to find another provider (much less the rare psychiatrists or addiction specialists), and further disappointment in our health care system. For many, once legal opioids were unavailable, their only recourse to treat their addiction and mitigate the symptoms of withdrawal has been to obtain them illegally.
Now, it’s easy to criticize clinicians. But recall from my previous blogs that most physicians are completely untrained in using opioids and have even less training in managing chronic pain patients and the usually associated mental health disorders such as depression. And they have virtually no training in managing opioid-dependent patients.
While the CDC had good evidence of the problems created by prescription opioid use, more than enough to justify not using them in the first place, there is far less evidence on what to do with people who are already taking them, especially when and how to decrease high dose opioids used chronically.
Based on evidence4 and consensus, I’m going to first summarize how we at Michigan State University approach the problem of chronic pain in patients not already taking opioids.5 Only if the following treatment approach fails would we consider starting treatment with opioids. The fundamental need is a strong clinician-patient relationship, one that respects the patient, listens to them, and negotiates (rather than dictates) treatment. Establishing the patient’s understanding of the problem and correcting, respectfully, any misunderstanding is the first step. For example, most patients erroneously believe that opioids are useful when, in fact, nonaddictive painkillers can be just as effective in pain management. Next, we obtain a commitment from the patient to the treatment program. It also helps to establish their long-term health goals to remind them of what they now may be missing out on because of poorly managed chronic pain. Depression and anxiety frequently co-occur with chronic pain, and are more likely the more severe the pain, the longer its duration, and the more pain sites involved. Treating depression and anxiety with medications and counseling results in far more pain relief than has been demonstrated with opioids. As well, this treatment can enhance sleep in the usually insomniac pain patient. Treatment with ibuprofen and acetaminophen also helps as does gradually increasing physical and social activity. Patients generally improve although seldom are cured.4
Now, to opioid use in patients already taking them. There are 3 options we negotiate with patients.5
- Taper and discontinue the opioid—in parallel with the above treatment approach. We begin by negotiating how many tablets they require on their worst days and having them take this amount on a fixed schedule set by the patient. For example, two upon arising, one mid-morning, one mid-afternoon, one at supper, and one at bedtime—six per day. Already having agreed to the taper, we have the patient decide which tablet to remove at the next visit in 1-3 weeks, so that they are down to five tablets per day at that point. We do the same at each subsequent 1-3 weeks follow-up visit until they have completely withdrawn from the opioid—always providing strong support and encouragement for a difficult task. How are they able to stop opioids? The above non-opioid treatment program is effective.4
- Taper to a safe dosage range in patients unable to discontinue. What is a safe dosage range: 50 to 90 milligram morphine equivalents.1 This is in the range of 2-4 tablets per day of common opioid medications like hydrocodone and oxycodone. Following the non-opioid treatment regimen and the same tapering strategy described above, we sometimes find patients are so dependent on the medications that they cannot fully taper and discontinue. This type of dependence is manifest by increased pain and becoming depressed and complaining bitterly about the tapering. If these symptoms do not abate by slowing the taper, we maintain them on a safe dose, periodically trying to resume the taper at a slow pace.
- Unable to taper to a safe dose. An unsafe dose in more than 90 milligram morphine equivalents per day. One follows the above treatment and initial tapering strategies but learns that the patient cannot even get to the safe opioid dose range because of severe distress with increased pain and depression. It can be helpful to obtain consultation with a psychiatrist or addiction consultant but given their frequent unavailability, it is permissible to keep the patient on the lowest dose that did not provoke worsening and periodically try to resume a very slow taper. If the full treatment program outlined above is implemented, these instances should be infrequent.
It is the unfortunate patients in the last two categories that have suffered from misapplication of the CDC guidelines and a dearth of psychiatrists and addiction specialists who might treat with buprenorphine or other measures. Their suffering is at least somewhat preventable by following the above guidelines for implementing proven treatments and by tapering the opioid to the lowest possible does without feeling compelled to stop it completely.
Tiia Monto — An abandoned toy on an edge of the Văcărești Nature Park, Bucharest
We believe our approach is more humane and matches the CDC clarifications3 and that it can suffice until research demonstrates better ways.
Copyright Robert C. Smith July 2019
1. Centers for Disease Control and Prevention. Prescribing Opioids for Chronic Pain. In: Prevention CfDCa, ed. Washington, DC: CDC; 2016.
2. Kroenke K, Alford DP, Argoff C, et al. Challenges with Implementing the Centers for Disease Control and Prevention Opioid Guideline: A Consensus Panel Report. Pain Med 2019;20:724-35.
3. Dowell D, Haegerich T, Chou R. No Shortcuts to Safer Opioid Prescribing. N Engl J Med 2019.
4. Smith RC, Lyles JS, Gardiner JC, et al. Primary Care Clinicians Treat Patients with Medically Unexplained Symptoms — A Randomized Controlled Trial. J Gen Intern Med 2006;21:671-7; PMCID: PMC1924714.
5. Smith R, D’Mello D, Osborn G, Freilich L, Dwamena F, Laird-Fick H. Essentials of Pschiatry in Primary Care: Behavioral Health in the Medical Setting. New York: McGraw Hill, Inc; 2019