Treating Chronic Noncancer Pain Amid an Opioid Crisis
This article is featured in the magazine, A Public Health Perspective on the Opioid Crisis. Download it now.
By Dr. Jennifer Sedillo, Faculty Member, Public Health, American Public University
Chronic noncancer pain, which is pain that has lasted longer than three months, affects one-third of adults in the United States. The CDC estimates that 11 percent of American adults experience daily pain. More people suffer from chronic pain than all other major chronic illnesses combined.
Pain is not only a physical ailment, but it can also affect a person psychologically and socially. It negatively affects a person’s social and work life and requires treatment to improve their quality of life and deter premature death.
Treating Chronic Pain
Treating chronic pain can be complex. Even when the causes of pain are known, it can still be difficult to manage. Chronic pain can come from many sources including migraines, fibromyalgia, low-back pain, arthritis, and other musculoskeletal diseases. However, oftentimes the underlying cause of pain is unknown, making treatment even more challenging.
Pharmacologic treatment includes the use of analgesics, such as nonsteroidal anti-inflammatory drugs (over-the-counter pain relievers), which are non-opioids. Opioids have also been regularly used to treat chronic pain. However, this pain-management strategy has gained national attention due to rapid increases in opioid addictions and overdoses.
Knowing the Risks of Opioids
Between 2006 and 2010, prescriptions for opioids steadily increased. As prescriptions increased, so did cases of addiction and subsequent overdoses.
Following acknowledgement that doctors were over-prescribing opioids, the rate of opioid prescriptions started falling in 2010, however, “[i]n 2017, 17.4 percent of the U.S. population received one or more opioid prescriptions, with the average person receiving 3.4 prescriptions.” The prescription rate hasn’t significantly changed since 2017. In 2018, women and persons older than 65 filled the most prescriptions for opioids.
Despite the overall decrease in prescriptions written for opioids, from 2006 to 2018 there was actually a significant increase in prescriptions for supplies of more than 30 days. During this same period, the number of prescriptions for extended release/long acting (ER/LA) opioids has decreased significantly.
Impacts of Long-Term Use of Opioids
Short-term usage of opioids has been found to be effective in reducing pain. Long-term usage, on the other hand, often has greater negative consequences. It may be surprising that there is no clinical evidence available to date that shows increased addiction with long-term opioid use. Instead, long-term use can lead to tolerance. When tolerance occurs, the dosage must increase. Increased dosages of opioids are found to be positively associated with addiction and overdose deaths.
Other risks for addiction come with prescription of ER/LA opioids, such as methadone, transdermal fentanyl, and extended-release versions of oxycodone, oxymorphone, hydrocodone, and morphine. These ER/LA opioids are also associated with increased risk of overdose.
Overall, there is currently no evidence for or against the effectiveness of opioids in long-term chronic pain management. There is some evidence that both duration and dosage of prescribed opioids can lead to adverse effects such as abuse and overdose, as well as motor vehicle injury. However, more studies should be completed.
In general, there aren’t enough clinical studies following patients for longer than six weeks. Given the severity of the risks involved with opioid use, there needs to be a clear risk-benefit analysis to justify their continued use.
Future of Opioids and Chronic Noncancer Pain Management
In response to the stark increase in opioid prescriptions and overdoses, the CDC has issued guidelines for physicians when prescribing opioids. The guidelines recommend that both non-pharmacologic and non-opioid pharmacologic therapy should be used in combination when opioids are prescribed. In addition, prescribers should carefully weigh the benefits and risks of prescribing opioids. These guidelines strongly advise against extended-release/long-acting opioids as these are associated with higher risk of overdose.
The report uses medical expert perspective to discuss guidelines for risk mitigation when patients are prescribed opioids including drug screening and monitoring of prescription-drug registry. Opioids should be used with extreme caution in patients with a history of drug abuse, overdose, or those who concurrently use benzodiazepine.
Furthermore, the goals of opioid therapy, and the risks of opioid use, need to be clearly established and a plan to discontinue opioid use if they don’t prove effective should be established prior to beginning therapy.
While opioids show effectiveness in relieving acute pain in short-term use, the overall use of opioids should decrease in the clinical setting and focus should shift to multi-modal therapy that addresses all aspects of chronic pain (see sidebar).
In addition to changing the way opioids are prescribed, the way chronic pain is managed needs to be addressed with more coordinated care efforts across medical disciplines with a decreased reliance on long-term pharmacological treatment.
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About the Author: Dr. Jennifer Sedillo has been a faculty member of Public Health at American Public University since receiving her doctorate in Public Health in 2014. Her expertise is in infectious disease research and microbiology. Her publications focus on cellular and molecular biology of infectious disease microorganisms. Her current research interests focus on foodborne illnesses and using social media to improve health education to the general public. To reach the author, email IPSauthor@apus.edu. For more articles featuring insight from industry experts, subscribe to In Public Safety’s bi-monthly newsletter.
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