JAMA: Opioids Should Not Be Eliminated to Treat Chronic Pain

An estimated 126 million adults in the United States have experienced some form of pain in the previous 3 months, and of them 25.4 million (11.2%) reported daily chronic pain and 23.4 million (10.3%) reported being in a lot of pain.

The chronic pain that is often experienced is prevalent, disabling, and costly; however, there have been greater efforts to reduce opioid use instead of working to increase pain relief, Kurt Kroenke, MD, of Indiana University School of Medicine, and Andrea Cheville, MD, of the Mayo Clinic, wrote in a JAMA Viewpoint article.

There has been a steady decrease in the analgesic options for chronic pain patients. Drugs like acetaminophen and nonsteroidal anti-inflammatory drugs have demonstrated a minimal efficacy for lower back pain, the leading cause of disability globally. The efficacy of multiple drug classes, like gabapentinoids and serotonin-norepinephrine reuptake inhibitors, remains unclear for treating broader chronic pain.

Opioid analgesics began to be used as an alternative for better pain management. However, as opioids became more common, the number of prescriptions, deaths from opioid overdose, and opioid misuse also increased. The authors suggest that the movement to eliminate opioids as an option for treating chronic pain as unnecessary since 5 to 8 million people in the United States use opioids for long-term pain management.

“Many patients currently receiving long-term opioids were started when opioids were still considered a viable treatment option and if satisfied with their pain control and using their medications appropriately should not be unilaterally compelled to wean off opioids,” the authors said.

The authors consider that only a very small proportion of opioid recipients transition to long-term opioid use. Of 10 million incident opioid recipients, by 1.5 years after the first prescription the probability of long-term use was 1.3%, 2.1% by 3 years, 3.7% by 6 years, and 5.3% by 9 years. Therefore, a minimal number of patients continue to use opioids for chronic pain and among those, the majority do not misuse the drug.

“An unintended consequence of excessive concerns raised about opioids could be an increasing reluctance among clinicians to prescribe even small amounts of opioids for a limited time for acute pain, including for patients discharged from the emergency department, those who are recuperating from surgical procedures, or persons with severe dental pain,” wrote the authors. “No clinician wants to be accused of contributing to the opioid “epidemic.” Meanwhile, some patients may be embarrassed about asking for effective pain relief.”

Despite the flaws among therapies for treating chronic pain, it is important to maintain options—even if only partially effective—in order to maximize the chances of managing chronic pain.