Perils of Pain Meds

I have read with interest the recent thoughtful editorials in The Rheumatologist about the future of rheumatology and our healthcare system in general. There is another problem affecting both the practice of rheumatology and primary care that is having a negative impact upon patient care, as well as on the careers of certain rheumatologists like myself. This problem concerns the overuse of prescription opioids for chronic non-cancer pain, including the rheumatic disorders—a practice which continues to grow with insufficient attention to the consequences. This has occurred irrespective of publications which confirm the importance of pain-relieving, non-drug therapies for most of the rheumatic disorders, as well as the pitfalls of opioid overuse for chronic non-cancer pain.^1-4 Some of these beneficial strategies include education, self-help courses, physical therapy and exercise programs, and psychological and behavioral approaches to pain management.

Growth of Opioid Use

The main controversy involves the difference between selectivity in the use of opioids in chronic non-cancer pain for specific clinical indications versus non-selectivity for most types of chronic pain represented by the movement to expand the use of opioids beyond the pain of cancer. Selective instances in which opioids may be beneficial include intractable tissue-generated pain, such as that caused by nerve disease or damage or end-stage arthritis, especially in the absence of other options. However, the use of opioids in other types of chronic non-cancer pain, especially that of central origin, may increase risks while the benefits may be minimal. Examples include central pain sensitivity states such as fibromyalgia syndrome, especially if associated with co-morbid depression or anxiety states.

Over the last decade, an expansion in the use of opioids has been advocated by certain pain specialists as well as pharmaceutical companies. In my opinion, this has occurred in the absence of valid data that support the claims that opioids can effectively and safely be extended beyond cancer to most patients with chronic non-cancer pain with a low risk of addiction. Such claims have subsequently been found to be inaccurate, and the original statement about the low rate of addiction to a common oxycodone sustained-release formulation has been shown to be false (as recently admitted by pharmaceutical company executives as a result of a Federal indictment).

Recent reviews confirm the absence of reliable long-term randomized controlled trials that demonstrate the efficacy and safety of opioid therapy for chronic non-malignant pain for more than eight months.^5-7 Further, in addition to increasing the risk–benefit ratio, over-reliance on long-term opioid therapy in rheumatic disorders may impede the learning of important self-efficacy and self-management skills that enhance favorable therapeutic outcomes with less dependence upon pain-relieving drugs.

Dangerous Drugs

Unfortunately, the non-selective and widespread use of prescription opioids, as well as illicit non-medical misuse, have contributed to a mounting toll of documented adverse events which were just starting to be recognized six years ago. This includes the high incidence of abuse and diversion, the substantial risk of addiction, the growing problem of opioid-related crime, the increased availability and ease of access to opiate drugs by teenagers and young adults (who misperceive prescription drugs to be safe), and the soaring statistics of emergency department visits, overdose, and death.⁸

Recent data from the Centers for Disease Control and Prevention (CDC) on national total opioid-related poisoning deaths (without heroin or cocaine) showed that from 1999 to 2002 (the last CDC-calculated year) there was a 129% increase in mortality, from 1,942 deaths in 1999 to 4,451 in 2002.⁹ Very likely, this figure has substantially increased in each subsequent year. A recent study in the Archives of Internal Medicine taken from drug mortality reports to the Food and Drug Administration (FDA), noted 5,548 oxycodone-related deaths from 1998 to 2005, making oxycodone the most common prescription drug of all drug mortality reports to the FDA.¹⁰ The actual number of deaths is probably much higher since most opioid-related deaths are not reported to the FDA. In Florida alone, as reported from the office of the Florida Medical Examiners in 2006, there were more than 4,300 total prescription opioid–related deaths with the three most common from methadone (974), oxycodone (923), and hydrocodone (731). Lethal levels were found in 716 cases of methadone, 496 cases of oxycodone, and 236 cases of hydrocodone, although many opiate-related deaths occurred in the absence of lethal levels but in combination with other central nervous system–active agents.¹¹

A Better Approach to Pain

In view of these statistics, there is a need to use opiate drugs selectively, prudently, cautiously, under close supervision, and for specific clinical indications. However, beneficial non-opioid self-management therapies are often neglected or underused, especially by primary care providers with not enough time to spend with their patients or because of a lack of or inadequate insurance coverage. This has led to a significant increase in the use of opioids (and other psychoactive agents) which has often resulted in polypharmacy and drug-dependent care becoming the rule for patients with every type of chronic non-cancer pain, particularly in rural areas.

I have observed many patients with intractable, non-inflammatory chronic pain, diffuse musculo-skeletal tenderness, and severe underlying psychological distress (particularly depression) who have been inadequately diagnosed and managed solely with opioids and polypharmacy. Many of these patients are drug dependent (and often addicted), dysfunctional both mentally and physically, and frequently on or applying for disability, which is especially common in the Medicaid population. Such patients may have had a better chance of responding to multidisciplinary management if timely specialty referrals were possible and were made at an earlier stage, prior to the start of opioid therapy, which often fosters passive treatment attitudes and “illness behaviors,” especially in the presence of poor coping skills and persistent psychosocial stress.

In view of the well-documented risks of opioids, careful patient selection and prudent use should be the standard. Pain should not be managed in isolation without an understanding of its roots, just as fever mandates a search for causes. Under-treatment should refer not only to drug therapy, but also to the absence of important non-drug interventions. Hopefully, this approach will reduce inappropriate opioid use as well as associated morbidity and mortality.

Dr. Gelfand is a rheumatologist at Cookeville Regional Medical Center in Cookeville, Tenn.

References

1. Bradley LA, Alberts KR. Psychological and behavioral approaches to pain management for patients with rheumatic diseases. Rheum Dis Clinics North Am. 1999;25(1):215-232.
2. Lemstra M, Olszynski WP. The effectiveness of multidisciplinary rehabilitation in the treatment of fibromyalgia: A randomized controlled trial. Clin J Pain. 2005;21(2):166-174.
3. Minor MA, Sanford MK. The role of physical therapy and physical modalities in pain management. Rheum Dis Clinics North Am. 1999;25(1):233-248.
4. Gelfand SG. The pitfalls of opioids for chronic nonmalignant pain of central origin. Medscape Rheumatology. 4(1), 2002. (www.medscape.com/viewarticle/425468).
5. Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Eng J Med. 2003;349:1943-1953.
6. Trescot AM, Boswell MV, Atluri SL, et al. Opioid guidelines in the management of chronic non-cancer pain. Pain Phys. 2006;9:1-39.
7. Martell BA, O’Connor PG, Kerns RD, et al. Opioid treatment for chronic back pain: Prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116-127.
8. Compton WM, Volkow ND. Major increases in opioid analgesic abuse in the United States: Concerns and strategies. Drug Alcohol Depend. 2006;81:103-107.
9. Paulozzi LJ, Budnitz DS, Xi Y. Increasing deaths from opioid analgesics in the United States. Pharmacoepidemiol Drug Saf. 2006;15:618-627.
10. Moore TJ, Cohen MR, Furberg CD. Serious adverse drug events reported to the FDA 1998–2005. Arch Intern Med. 2007;167(16):1752-1759.
11. Florida Department of Law Enforcement. 2006 report of drugs identified in deceased persons by Florida Medical Examiners. June 2007. (www.fdle.state.fl.us/publications/Examiners/2006DrugReport.pdf)