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NIH Report: Insufficient Evidence for Opioid Use in Chronic Pain

Position paper cites lack of decision support for chronic pain management

Evidence is insufficient for opioid use in chronic pain, according to a position paper published online January 13 in the Annals of Internal Medicine.

David B. Reuben, MD, of the David Geffen School of Medicine at the University of California in Los Angeles, and colleagues examined the role of opioids in the treatment of chronic pain, based on an evidence report that was prepared in September 2014 for a National Institutes of Health workshop. At that meeting, an independent panel identified research gaps and future research priorities related to the use of opioids in the management of chronic pain.

According to the 2014 report, chronic pain affects an estimated 100 million Americans, or one-third of the U.S. population. Approximately 25 million people experience moderate-to-severe chronic pain with significant pain-related activity limitations and diminished quality of life. The societal cost of chronic pain has been estimated at between $560 and $630 billion per year as a result of missed work days and medical expenses.

An estimated 5 million to 8 million Americans use opioids for the long-term management of chronic pain, and opioid prescriptions have increased dramatically over the past 20 years, according to the report. For example, the number of prescriptions for opioids written for pain treatment in 1991 was 76 million; in 2011, that number reached 219 million. This increase in opioid prescriptions has paralleled an increase in opioid overdoses and overdose-related hospital admissions.

A major influence on opioid prescribing is the evolution of the larger health-care system and the current state of primary care, according to the report. The workshop panel heard reports of major problems with the current health care system, including:

  • Poor support for team-based care and specialty pain clinics
  • Over-burdened primary care providers
  • A lack of knowledge and decision support for chronic pain management
  • Financial misalignment favoring the use of medications
  • Fragmentation of care across different providers

The panel also noted several specific research issues that merit further exploration. These include the following:

  • Better understanding is needed of the window between the effective dose and the dose at which adverse outcomes occur.
  • In adverse outcomes research, it is important to determine how best to model more-immediate versus longer-term adverse effects based on the length of exposure to opioids.
  • Few studies have looked at genetic predictors of response and poor outcomes.

In the new article published in the Annals of Internal Medicine, Reuben and his colleagues note that patients who are in pain are often denied the most effective comprehensive treatments because of inadequate knowledge regarding the best approaches for the treatment of various types of chronic pain. Insufficient evidence is available for every clinical decision a provider needs to make about the use of opioids for chronic pain; consequently, providers must rely on their clinical experience, the authors write.

Because of the inherent difficulties of studying pain and the large number of patients already receiving opioids, the article calls for new research designs and analytic methods to adequately answer important clinical and research questions.

Reuben and his colleagues conclude: “The challenge is to identify the conditions in patients for which opioid use is most appropriate; the optimal regimens; the alternatives for those who are unlikely to benefit from opioids; and the best approach to ensuring that every patient’s needs are met by a patient-centered health care system.”

Sources: Medical Xpress; January 13, 2015; Annals of Internal Medicine; January 13, 2015; and NIH; September 2014.

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