AAN: Risks of Opioids Outweigh Benefits for Many Conditions
The risk of death, overdose, addiction, or serious side effects outweighs the benefits for patients taking prescription opioids to treat a number of chronic, non-cancer conditions, according to a new paper in the journal Neurology.
The position statement from the American Academy of Neurology (AAN) addresses risks, evidence-based research, federal and state policies, and best practices regarding this class of pain medications, which includes morphine, codeine, oxycodone, methadone, fentanyl, hydrocodone, or a combination of these drugs with acetaminophen.
______________________________________________________________________________________________________________________________________________________
RELATED CONTENT
Opioids the New Drug of Choice for Children
Opioids With Abuse-Deterrent Technologies
______________________________________________________________________________________________________________________________________________________
“There is low evidence of effectiveness, but very high evidence of serious harm, especially for routine conditions, such as headache, low back pain, and fibromyalgia,” says AAN Fellow and opioid expert Gary M. Franklin, MD, MPH, of the University of Washington in Seattle, who authored the statement.
That evidence includes more than 100,000 deaths directly or indirectly caused by prescribed opioids in the United States since policy changes in the late 1990s allowed for much more liberal, long-term use. More Americans ages 35 to 54 have died from prescription opioids than from firearms and motor vehicle accidents, the statement says.
Studies have shown that 50% of patients taking opioids for at least 3 months are still taking the drugs 5 years later. A literature review suggests that while opioids may provide significant short-term pain relief, there is no substantial evidence for long-term maintenance of pain relief or improved function without serious risks of drug overdose, dependence, or addiction.
“Risk is especially increased for a serious overdose event above 100 mg/day morphine equivalents, but 2 studies showed a fourfold increased risk even between 50 mg/day to 99 mg/day,” Franklin says. “One also has to consider that dependence (trouble withdrawing) probably is nearly universal after only 3 months of treatment, and addiction is likely much more common than previously thought.”
The AAN recommends consulting with a pain management specialist if the dosage exceeds 80 mg/day to 120 mg/day (morphine-equivalent dose), especially if the patient’s pain and function have not substantially improved.
The statement also offers a number of suggestions for health care providers to prescribe opioids more safely and effectively, including:
• Create an opioid treatment agreement.
• Screen for current or past drug abuse as well as depression.
• Administer random urine drug screenings.
• Don’t prescribe medications such as sedative-hypnotics or benzodiazepines with opioids.
• Assess pain and function for tolerance and effectiveness.
• Use an online dosing calculator to track daily morphine-equivalent dose.
• Monitor all prescription drugs the patient may be taking using the state Prescription Drug Monitoring Program.
Franklin hopes to see much more funding for the use of non-opioid therapies for the treatment of pain, including graded exercise, activity coaching, cognitive behavioral therapy, and multidisciplinary pain treatment.
“It will also be important to develop community-based resources to more effectively coordinate care for those in pain, with the principal goal of preventing the transition from acute/subacute pain to chronic pain,” he says.
—Colleen Mullarkey
Reference
Franklin GM. Opioids for chronic noncancer pain: A position paper of the American Academy of Neurology. Neurology. 2014 Sep 30;83(14):1277-84.