As ever more scrutiny is focused on the use of opioids in the United States, two principles about their use for chronic pain should loom largest in clinicians’ minds, advises Richard W. Rosenquist, MD, Chairman of Cleveland Clinic’s Department of Pain Management:
- The role of opioids in treating chronic pain is very small and limited to a narrow subset of patients.
- Any plan to start a patient on opioids must include a plan to monitor their effect using specific outcome measures and to stop their use if defined treatment goals aren’t met.
“In general, pain specialists rarely prescribe opioids anymore for chronic pain unless it’s cancer-related pain,” says Dr. Rosenquist.
Overcoming a Misjudgment from a Quarter Century Ago
But it wasn’t always that way. In the late 1980s, an effort took hold among pain specialists to improve chronic pain treatment through expanded opioid use. “Opioids were known to be effective for acute pain, so the thinking was, Why not use them for patients with chronic pain who needed greater relief?” explains Dr. Rosenquist.
Many pain specialists at the time believed that if chronic opioids were limited to legitimate indications, patients would not become addicted. “But reality caught up with us,” Dr. Rosenquist notes. “We learned that people who get started on opioids have a much higher conversion to active addiction than previously thought. Also, physical dependence on opioids develops quickly, and in some people it turns into physical addiction.”
A Steep Societal Toll
These lessons did not become clear for years, however, and prescribing of opioids surged during the 1990s and early 2000s. Opioid abuse increased in tandem, and the consequences have been filling headlines for several years now:
- 15,000 to 18,000 U.S. deaths per year attributable to prescription opioid overdose
- The proliferation of — and later crackdown on — “pill mills” that spurred a subindustry of individuals reselling opioids for profit
- Burgeoning rates of addiction to heroin, a less-expensive opiate that addicts turn to for cost reasons or when they can no longer access prescription opioids because of the pill mill crackdown
Other Reasons to Nix Chronic Opioids
These huge addiction-related costs are a major reason why the pain medicine community has dramatically scaled back use of opioids for chronic pain in recent years — but they are hardly the only one, says Dr. Rosenquist.
Another reason is disappointing efficacy. “People thought opioids had no ceiling effect, but it turns out they don’t yield much pain relief in the chronic setting,” he explains. “After a while, patients are lucky to get 20 or 30 percent relief.” Improvement in functional outcomes and general well-being is often even less, he adds.
Many patients on chronic opioids feel worse overall because of these agents’ now well-established side effects, including immunosuppression, endocrine abnormalities, constipation, sedation and depression. Cruelest of all, some patients experience worsened pain after starting chronic opioids, an effect known as opioid-induced hyperalgesia.
The Rare Cases When Chronic Opioids Are Indicated
So when do Dr. Rosenquist and his colleagues consider opioids outside the acute pain setting?
“We’ll look at them for managing cancer pain when we have no other alternatives,” he says (see next story). “We also will consider them when there are medical contraindications to other choices for pain control. In those cases, we use opioids in low doses and aim to maintain the dose at a steady state. In general, high doses are rarely successful.”
He adds that continued opioid use is contingent on demonstrated improvements in functional outcomes, not just pain scores. “If you give an antibiotic for a UTI and it doesn’t treat the infection, you stop it. The same principle applies. Many patients are on opioids for a long time without ever achieving a good outcome, yet they and their providers fail to question it and try something different.”
Today’s Challenge: Caring for Displaced Patients
Many of the Department of Pain Management’s current efforts surrounding opioids aim to address the needs of those patients. That’s especially true now that many unscrupulous providers have stopped prescribing opioids in the wake of regulatory crackdowns, leaving their patients desperate for new prescribers. The Department of Pain Management is implementing a new algorithm for managing these displaced patients.
The foundation of the approach is simply getting patients to the right provider after an evaluation of their pain and current opioid use status. Patients whose condition includes an addiction component need to have that addressed first, so they are referred to Cleveland Clinic’s Alcohol and Drug Recovery Center or its distinctive interdisciplinary Chronic Pain Rehabilitation Program. The latter is a three- to four-week outpatient program designed to reduce both pain and chemical dependency and foster coping skills and improved function.
Once addiction is addressed, Dr. Rosenquist’s team restarts the patient’s pain management with a proper evaluation to uncover the underlying cause of the pain process. That typically leads to multimodality treatment that may include psychological approaches, interventional approaches, physical therapy and more. “What we often offer could be called a pain wellness program.”
Beyond these efforts, the Department of Pain Management is partnering with Cleveland Clinic’s Digestive Disease and Surgery Institute and Neurological Institute to develop a novel care path and multidisciplinary clinic specifically for chronic abdominal pain. A major impetus is the prevalence of inappropriate opioid use. “I can’t think of anything with less evidence than using opioids for abdominal pain,” says Dr. Rosenquist, “so we’re aiming to tackle that problem head-on.”
In the end, he sees opioids “not as the root of all evil but something to be used very carefully. A decision to use an opioid should be made with good understanding and clear expectations about what it should do. If it doesn’t do what’s intended, stop the drug.”
Dr. Rosenquist can be reached at 216.445.8388 or firstname.lastname@example.org.