Evidence does not support use of long-term opioid therapy for chronic pain

January 21, 2015, 11:14 pm

RxOpioids170★★★½☆

The Effectivenss and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop. Chou R et al.  Ann Intern Med 2015 Jan 13 [Epub ahead of print]

Abstract

Although prescription opioids have been advocated and used for long-term treatment of chronic non-cancer pain, there is scant literature supporting such use. Most studies have been limited to a time period of 3 months or less. The purpose of this literature review was to assess the evidence pertaining to safety and effectiveness of long-term (> 1 year) opioid therapy for pain.

The authors point out that when evaluating this question, in addition to potential benefits of pain relief, known risks of opioid therapy must be considered, including falls, fractures, motor vehicle accidents, and endocrinopathy. In addition, level of function and quality of life must be assessed.

The authors searched several databases for relevant English-language literature published between January 2008 and August 2014. Among their findings:

  • “No study of opioid therapy versus placebo, no opioid therapy, or nonopioid therapy evaluated long-term (> 1 year) outcomes related to pain, function, or quality of life.”
  • “No randomized trial evaluated opioid abuse, addiction, or related outcomes with long-term opioid therapy versus placebo or no opioid therapy.”
  • “One good-quality case-control study (5300 case patients) found that MEDs [morphine equivalent doses] of at lest 20 mg/d were associated with increased odds of road trauma among drivers.”
  • “No study evaluated risk for falls; infections; or psychological, cognitive, or gastrointestinal harms among patients with chronic pain who were receiving long-term opioid therapy versus placebo or no opioid therapy.”

In addition, the authors found that: “Evidence on the accuracy and effectiveness of risk assessment instruments for predicting opioid abuse or misuse in patients before initiation of  long-term opioid therapy was sparse . . .”

Their conclusion:

In summary, reliable conclusions about the effectiveness of long-term opioid therapy for chronic pain are not possible due to the paucity of research to date. Accumulating evidence supports the increased risk for serious harms associated with long-term opioid therapy, including overdose, opioid abuse, fractures, myocardial infarction, and markers of sexual dysfunction; for some harms, the risk seems to be dose-dependent.

In a related development, last week’s issue of MMWR reported that although the rate of increase in drug fatalities related to opioid analgesics has levels off some, the rate of such increased from 199 to 2013 by almost a factor of 4:

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[Chart from MMWR 2015 Jan 16;64:32]

4 Comments:

  1. jim` Says:

    It would be hard to quanitify, but the cumulative stress of chronic pain is a factor to be considered in favor of opiates and/or other analgesics. I’ve personally found this to be the case: a few days of pain, noproblem; but week after week the strss takes a toll.

  2. Leon Says:

    Jim:

    I completely agree that chronic pain is a major health problem and should be optimally controlled. The problem is that there is no evidence that opioids, by and large, are safe and effective for that indication. As TPR has discussed before, addiction, profession to heroin use, opioid-induced hyperalgesia, and narcotic bowel syndrome are just some of the adverse effects that occur and vitiate any potential beneficial effects. Certainly, some chronic pain patients may benefit from opioids, especially when they are used as part of a comprehensive program. But on a population basis, the risks clearly outweigh any potential benefits.

  3. Will Says:

    Leon

    As a chronic pain sufferer on and off for about 35 years I have come to realize that there is a lot of opinionated observations by those who have never had to deal with the problem. When a person has chronic pain it can and does cause the person to also suffer from a lower quality of life. It has been my experience that nothing gets rid of the pain, but only dulls it in order to make it bearable. If there was a study done on the drug, thought by the medical community to be the drug of choice for chronic pain, they would find that it is far more dangerous and more widely abused than opioids. But, no one in the medical community would ever challenge that so called ” Miracle Drug” Ibuprophen. I have had a bleed out from a stomach ulcer caused by aspirin. I am unable to take any NSAIDs because of that, and so, am limited to using opioids. I don’t abuse them, I’m not addicted to them, they just make my pain bearable so that I can live a life unconfined to a chair or bed. Recently the DEA has reclassified Hydrocodone because of many of the problems shared with the “declassified Ibuprophen”. Because of this my doctor is trying to take me off Hydrocodone. They first prescribed a newer NSAID with a full page of possible, and some horrible, side effects. They are more concerned with the DEA and popular opinion than my physical well being.

  4. Dr. Basim Elhabashy Says:

    A large number of people are suffering from chronic pain in country that is not good for health. At that time the patient needs proper treatment.