Monday, June 20, 2016

Chronic opioid therapy - who, when, how?

- Jennifer Middleton, MD, MPH

A significant portion of the June 15 issue of AFP is devoted to chronic opioid use in patients with non-malignant pain. The issue provides an overview of Weighing the Risks and Benefits of Chronic Opioid Therapy along with reviewing the Centers for Disease Control's (CDC) new guideline for opioid prescribing with accompanying editorials from the CDC and the American Medical Association (AMA). The messages from these sources are consistent: the evidence base supporting the efficacy of chronic opioid use is limited but certainly some patients benefit, other modalities should be our first choice when possible, and monitoring for misuse or addiction is of critical importance. None of these recommendations are likely to come as a surprise to family physicians, but the challenges with identifying the right patients to treat, being aware of alternative modalities to offer, and providing effective monitoring may still remain for many practices.

The Risks and Benefits article provides guidance regarding the initiation, maintenance, and discontinuation of chronic opioid therapy. Assessing for risk of overdose and counseling patients regarding risks of opioid use are reviewed in Tables 3 and 4. Patients at lower risk of overdose, who have failed alternative treatments, and are willing to comply with ongoing monitoring are more ideal candidates for chronic opioid therapy.

Alternatives to using opioids for treating chronic pain have been studied with various degrees of rigor depending on the underlying source or cause. For chronic low back pain, several non-pharmacologic methods have evidence of at least short-term efficacy, but, unfortunately, acetaminophen does not  help in the short- or long-term, and NSAIDs should be used with caution.

Physical therapy and tai chi help knee osteoarthritis (OA) pain as does general exercise and weight loss; corticosteroid injections may help, though hyaluronic acid injections and glucosamine/chondroitin supplements don't. For upper body OA sites, splinting reduces hand pain, and corticosteroid injections and manipulation can help shoulder pain.

Exercise reduces fibromyalgia symptoms, and aquatic therapy helps stiffness and quality of life but doesn't necessarily reduce pain. Counseling, especially cognitive behavioral therapy, can be quite beneficial for patients with fibromyalgia, and several non-opioid medications can also provide some relief. The data to date for opioids in treating the chronic pain of fibromyalgia does not show any benefit.

A Family Practice Management (FPM) article from 2014 reviews helpful office protocols for monitoring patients on chronic opioids. The authors share their office policies for prescribing controlled substances, including opioids, and also discuss the use of patient pain questionnaires, risk assessment tools such as SOAPP, controlled substance agreements, urine drug screening, and prescription drug monitoring programs. Each office will want to tailor its plan to best meet its population's needs, but there are a lot of useful resources in this article to help you do so.

Identifying the most appropriate patients for chronic opioid therapy, trying alternative treatments, and monitoring patients can be challenging and time-intensive and, ideally, engages your entire office team. For more resources, there's an AFP By Topic on Pain:Chronic that includes the above referenced AFP and FPM articles and also includes information about neuropathic pain, more office-based tools, relevant Curbside Consultation features, and patient education materials.