Is It Wise To Dismiss Opioids For Chronic Pain?

Today's post from thebodypro.com (see link below) is directed at people living with HIV and chronic pain conditions such as neuropathy (around 40% of HIV patients also suffer from nerve damage) but also applies to the general population if they have a chronic pain condition - irrespective of the cause. That said, the article comes over as a little confused; as if the author isn't sure on which side of the fence she sits regarding opioid prescription and use. The underlying message that opioid prescription should be a last resort for chronic pain is indisputable but the idea that the cause of the pain should first be dealt with, is simply inapplicable to people with most chronic pain conditions for which there is no cure and certainly for HIV patients, cancer patients and the like. She also suggests that evidence of opioid effectiveness is limited, when there are countless studies that show that opioids are an extremely effective way of suppressing pain...if handled properly, with sufficient after-care. She also rolls out the addiction problem: "evidence of their risks is mounting, with an estimated 10% of patients on such medications becoming addicted"! Surely this advances the efficacy of opioids because by definition, 90% of patients do not become addicted!! Whether this article will change your opinion on opioids is for you to decide but when it comes to chronic pain conditions, the idea that they can be treated just with behaviour change, is way too simplistic. Experienced neuropathy patients will know all too well the hoops they have to jump through in order to get their pain under control and are well aware of the gamut of other dangerous medications they have to try before reaching the opioid stage. Fear of opioids may lead to much more unnecessary suffering than is needed.

Opioids Are Not a First-Line Treatment for Chronic Pain, Pain Specialist Says
By Barbara Jungwirth From TheBodyPRO.com October 6, 2016



When someone living with HIV complains about chronic pain, take their word for it, but try non-opioid therapies and treat underlying psychiatric illnesses before prescribing oxycodone, Jessica S. Merlin, M.D., M.B.A., advised health care providers in a recent webinar. People living with HIV are more likely to suffer from such pain (30%-85% report chronic pain) than the general population (15% report that issue). This may be partly due to greater sensitivity to pain in those with detectable viral loads, Merlin explained.

Providers must understand the impact that this condition has on a patient's daily life, screen for mood disorders and note the patient's coping strategies before suggesting a therapy approach, Merlin advised in the Chronic Pain in HIV Infection: A Practical, Evidence-Based Approach webinar sponsored by the International Antiviral Society-USA on August 18, 2016. An effective technique Merlin has used in her chronic pain clinic is motivational interviewing, which is designed to stimulate people's own motivation for change, rather than simply telling them that they should change their behavior. She counseled providers to educate patients about ways to control pain without resorting to prescription medications, including mind-body techniques and short-term, over-the-counter drugs, such as acetaminophen. The latter, however, has problematic side effects when taken long-term, especially in combination with antiretrovirals, Merlin cautioned. Other approaches include physical therapy and exercise, as well as topical medications.

Providers should develop a team either within their office or within the community; it should include mental health professionals, methadone programs and social workers, among others. Such a team approach allows for better screening and treatment of depression, PTSD and other conditions that may co-occur with chronic pain. These problems need to be addressed first to remove the underlying cause of the pain, rather than treating only the symptoms.

Opioids should not be considered first-line therapy for chronic pain, Merlin emphasized. Evidence of their benefit is limited, and no studies have evaluated their use for longer than one year. By contrast, evidence of their risks is mounting, with an estimated 10% of patients on such medications becoming addicted, as well as a risk of overdose, especially when co-prescribed with benzodiazepines. Providers should take universal precautions when prescribing opioids, rather than deciding who is or is not at risk of opioid use disorder. These precautions include having the patient sign an opioid treatment agreement, with provisions for using only one prescriber and one pharmacy and submitting to frequent urine drug testing. However, urine tests can result in false positives, especially when someone takes multiple medications, as is the case with those living with HIV, Merlin noted. A confirmatory assay, as well as a conversation with the patient, are therefore necessary before jumping to conclusions.

If all non-opioid attempts at managing the chronic pain have failed and oxycodone or a similar drug is prescribed, the lowest effective dose should be used. Patients should be re-assessed at least every three months, other therapies should be optimized, and the opioid dosage prescribed should be tapered off over time with the goal of eventually discontinuing it altogether. Merlin also advocated co-prescribing naloxone for high-risk patients, if they can bring in someone who lives with them and can administer the antidote in case of opioid overdose. However, local laws differ as to whether this approach is permitted. Laws on marijuana use also differ among states, but where legal the substance may be useful in treating chronic pain. Evidence shows that people who are prescribed medical marijuana use opioids less, reducing the risks associated with opioids.

Barbara Jungwirth is a freelance writer and translator based in New York.

Follow Barbara on Twitter: @reliabletran.

http://www.thebodypro.com/content/78544/opioids-are-not-a-first-line-treatment-for-chronic.html