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A closer look at opioids for chronic pain

The Bottom Line

  • People taking opioids (painkillers that include morphine, codeine, methadone and oxycodone) for more than three months are at higher risk of drug abuse, addiction and overdose, as well as heart attack.
  • Opioids may actually only provide limited relief. Tolerance to these drugs means many patients need increasing doses to manage pain, which can increase risk of harm.
  • Before taking medications, try alternative treatments for your chronic pain, such as antidepressants, exercise, acupuncture or mindfulness.
  • Physicians are urged to prescribe opioids as a last resort for chronic pain and restrict dosages when they are prescribed. Opioid management tools may help.

Many people who suffer from chronic pain often seek more than an over the counter medication to help them make it through the day. Opioid-based drugs – such as morphine, methadone, fentanyl, oxycodone (OxyContin®) and hydrocodone (Vicodin®) among others –  are commonly prescribed in North America to help ease the burden of chronic pain (1). But what to do when pain relief from these ‘heavy hitters’ comes with a risk of serious consequences?


Chronic pain, defined as pain that lasts more than three months or past the normal time for healing, is common. Chronic pain that isn’t related to cancer affects about 20% of Canadian adults (2, 3). Older adults are particularly vulnerable as they are more likely to have conditions that contribute to chronic pain such as osteoarthritis, rheumatoid arthritis and low back pain (4).


Ironically, it was partly due to concerns about the potential dangers of “NSAIDS,” commonly used anti-inflammatory pills including aspirin and ibuprofen, that doctors began prescribing opioids (5). For the past few decades their use has increased dramatically in North America. For example, from 1999 to 2010, the amount of prescription opioids sold in the U.S. nearly quadrupled (6).


So how has that worked out? As we’ve witnessed, it has sparked a drug epidemic and a public health crisis due to drug dependency, addiction and overdose. Between 1999 and 2008, deaths due to opioid drug overdose in the U.S. – nearly half a million – also quadrupled (6). In Canada, a “tidal wave” of fentanyl overdoses has spread across the country, accounting for 30% of opioid related deaths in Ontario, according to Chief Coroner Dirk Huyer (7). It is important to acknowledge the contribution of illicit (non-prescription) opioids to this epidemic, as well as issues related to prescribed opioids getting into the hands of others… typically for non-medical use.


This connection between increased prescribing of opioids and the number of opioid-related deaths is no coincidence, as recent research has shown. Thirty-nine studies were part of a recent systematic review aimed at informing the effectiveness and risks of long-term opioid use for relieving chronic pain (8).


What the research tells us

The review authors found no randomized controlled trials that measured the benefits and/or harms of opioid use for a year or more. While this review highlights the urgent need for more research on longer term use, as clinical reviewers have noted (8), the review serves as a “wake up call” and provides more data to dissuade us from prescribing narcotics for chronic pain.


Meanwhile, there is increasing evidence that opioids, on average, provide very limited relief of chronic pain, with no increased benefit at higher doses (8, 9). Many experts concur, suggesting that the tendency to increase dosages as patients remain sensitive to pain but more tolerant of the drug, can increase risks of addiction and overdose (9, 10).


What now?

So, if NSAIDs and opioids are associated with limited benefits and significant harms when used for managing chronic pain, what do we do? So far, a safe and effective cure for chronic pain has been frustratingly elusive and the focus of treatment is shifting to managing pain vs getting rid of it. For now, doctors are urged to prescribe opioids only as a last resort and to restrict daily doses to ≤90 morphine milligram equivalents (MME) except in exceptional circumstances (11, 12).


If you are living with chronic pain, try a low dose tricyclic antidepressant (e.g. Amitriptyline) (13) or non-drug therapies such as exercise, acupuncture, or mindfulness training (14-17).


If your doctor has prescribed opioids for your pain, start with the lowest possible dose. Keep in mind that physical dependence will develop in anybody taking opioids long-term, and symptoms of opioid withdrawal may prevent some people from reducing their opioid dose to meet the ≤90MME threshold. Talk to your doctor about this possibility and strategies to manage your pain while reducing your dose (18). There are programs and tools available to help monitor and manage opioid prescriptions. For example, the CDC Opioid Guideline Mobile app, Checklist for prescribing opioids for chronic pain, or the McMaster’s DeGroot Pain Centre’s “Opioid Manager”, also available as an app.


Chronic pain is an important and challenging issue, but it’s imperative that any management options provide benefits that outweigh their risks.


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References

  1. Centers for Disease Control and Prevention. Safer, more effective pain management. [Internet] 2016. [cited January 2017]. Available from https://www.cdc.gov/drugoverdose/prescribing/patients.html
  2. Institute of Medicine. Relieving pain in America: A blueprint for transforming prevention, care, education and research. Washington, DC: National Academies Pr; 2011.
  3. Schopflocher D, Taenzer P, Jovey R. The prevalence of chronic pain in Canada. Pain Res Manag. 2011; 16(6): 445–450.
  4. Michael G DeGroote National Pain Centre. Epidemiology of chronic non-cancer pain (CNCP). [Internet] 2017. [cited January 2017]. Available from https://www.cdc.gov/drugoverdose/prescribing/patients.html
  5. King S. Chronic pain management in the elderly: An update on safe, effective options. Consultant 360. 2012; 52(5).
  6. Centers for Disease Control and Prevention. Vital signs: Overdoses of prescription opioid pain relievers – United States, 1999 – 2008. [Internet] 2011. [cited January 2017]. Available from https://www.cdc.gov/drugoverdose/prescribing/patients.html
  7. Andrew-Gee E. Fentanyl deaths on the rise in Ontario: Coroner. [Internet] 2016. [cited January 2017]. Available from https://www.cdc.gov/drugoverdose/prescribing/patients.html
  8. Chou R, Turner JA, Devine EB et al. The effectiveness and risks of long-term opioid therapy for chronic pain: A systematic review for a national institutes of health pathways to prevention workshop. Ann Intern Med. 2015; 162:276-86.
  9. Abdel Shaheed C, Maher CG, Williams KA, Day R, McLachlan AJ. Efficacy, Tolerability, and Dose-Dependent Effects of Opioid Analgesics for Low Back Pain: A Systematic Review and Meta-analysis. JAMA Intern Med. 2016 Jul 1;176(7):958-68.
  10. Dunn KM, Saunders KW, Rutter CM et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010; 152:85-92.
  11. Dowell D, Haegerich TM, Chou, R. CDC guideline for prescribing opioids for chronic pain – United States, 2016. MMWR Recomm Rep. 2016; 65(1):1-49
  12. Frieden TR, Houry D. Reducing the risks of relief – The CDC opioid-prescribing guideline. N Engl J Med. 2016; 374(16):1501-1504
  13. Griebeler ML, Morey-Vargas OL, Brito JP, et al. Pharmacologic interventions for painful diabetic neuropathy: An umbrella systematic review and comparative effectiveness network meta-analysis. Ann Intern Med. 2014; 161:639-49.
  14. O’Connor SR, Tully MA, Ryan B, et al. Walking exercise for chronic musculoskeletal pain: systematic review and meat-analysis. Arch Phys Med Rehabil. 2015; 96:724-34.
  15. Fransen M, McConnell S, Harmer AR, et al. Exercise for osteoarthritis of the knee. Cochrane Database Syst Rev. 2015; 1: CD004376.
  16. Chou R, Deyo R, Friedly J, et al. Noninvasive treatments for low back pain. Rockville (MD): Agency for Healthcare Research and Quality (US); 2016 Feb. Report No.:16-EHC004-EF (Review) h
  17. Theadom A, Cropley M, Smith HE et al. Mind and body therapy for firbromyalgia. Cochrane Database Syst Rev. 2015 Apr 9; CD001980. doi: 10.1002/14651858
  18. Busse JW, Juurlink D, Guyatt GH. Addressing the limitations of the CDC guideline for prescribing opioids for chronic noncancer pain. CMAJ. 2016 Dec 6;188(17-18):1210-1211.

DISCLAIMER: The blogs are provided for informational purposes only. They are not a substitute for advice from your own healthcare professionals.

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