Pain needs painkillers right?

Overprescribing of opioid painkillers has caused harm to many people. Problems

include addiction, loss of social functioning and increasingly, though still relatively
uncommonly in the UK, to death.
Concerns have been raised about deaths associated with tramadol in particular. Ive
written before about the lack of evidence of effectiveness for opiates in chronic pain,
but it is hard for clinicians to resist the slippery slope of initiating and then increasing
opioid strength or dose when faced with a patient reporting pain. !here is an e"pectation
that pain needs painkillers # there is arguably a culture of prescribing opiates for
chronic pain. $ut thats %ust common sense # right&
Warnings
'ets not be so fast. (ecently pain specialists and neurologists have become more vocal
about warning against prescribing for chronic non)cancer pain. !he *merican *cademy
of +eurology has %ust issued a review and position paper on the sub%ect written by ,r
-ary .ranklin of the University of /ashington.
!he driver behind the initiative is the 011,111 *mericans who have died, directly or
indirectly, from prescribed opiates in the U2 since the late 0331s. !his is more than died
from (!*s and firearms. !his is far more than the number of U2 military personnel
who died in the 4ietnam war. It truly is an epidemic # a national tragedy # and it looks
like it is one which could have been avoided or one that could at least be ameliorated. It
is one that is caused by non)evidence based prescribing.
Diversion
,iversion and inappropriate use of opioids is a problem. !he paper illustrates the point5
In one population)based study in Ontario, Canada, of all deaths attributable to opioids
during 6117#6118, 9: of patients had died from opioids diverted from friends or
family, and 03: had inappropriately self)administered ;e.g., inhaled, in%ected<. * greater
proportion of deaths may be associated with diversion in rural states.
Risk to benefit balance
!he effectiveness of opiods in chronic pain is uncertain and this is, as the paper
graphically illustrates, grossly outbalanced by the down sides5
=ortality
Overdose morbidity
2erious adverse events
,ependence>*ddiction
'ifelong disability
'oss of family and community
Recommendations
!he paper makes some clear best)practice recommendations which Ill paraphrase5
0. ?ave an agreement with the patient at the outset that identifies the risks and
outlines the patients responsibilities
6. Identify current or past substance misuse
@. Identify risk of depression
A. Use urine to"icology prudently ;identify diversion or misuse of other
substances<. 2creen before starting.
B. Use tools to track pain and function and monitor tolerance
7. !rack the amount of opioids used daily) converted to the eCuivalent dose of
morphine ;=D,<
9. -et further help if the =D, reaches 81)011mg and there is no significant pain
improvement.
8. Use a programme available in most states to monitor Eall sources of controlled
substances.
A different approach to pain
!hese recommendations are solid though I would have liked them to include something
that is mentioned elsewhere in the paper # to address pain in a holistic way. /hy is pain
always seen as something to be instantly medicated, solved by a pill& Pain is a comple"
symptom with biological, psychological and social influences. .ranklin writes5
In addition payers need to offer adeCuate payment incentives for treatment alternatives
to the opioid prescription for acute, subacute, and chronic pain. Cognitive#behavioral
therapy, structured e"ercise, spinal manipulation, and interdisciplinary rehabilitation,
although proven to be moderately effective in treating subacute and chronic low back
pain, are often either not available or not adeCuately funded.
* collaborative care model for the care of patients with chronic pain, not unlike similar
models aimed at chronic disease management of diabetes and other con) ditions, should
be a crucial element in the evolving health care reform environment.
The conclusion?
It seems likely that, in the long run, the use of opioids chronically for most routine
conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not
prove to be worth the risk.
*nd the risk for those with a vulnerability to addiction is significant. Prescribing for
pain is a common route of entry into opioid addiction.
Prescribers and patients
$ut we have a lot of work to do to change the prevailing culture. !ime =agaFine picked
up on this paper in a recent article. !hey highlight the challenges around changing the
culture of prescribers5
In 611@, ,r. Gane $allantyne and ,r. Gianren =ao, then at =assachusetts -eneral
?ospital and ?arvard =edical 2chool, published a review of the e"isting data on opioid
use for chronic pain in the New England Journal of Medicine. It was among the first
studies to highlight the fact that the skyrocketing number of prescriptions was doing
little to actually reduce reports of chronic pain.
H!he real problem is physicians who are practicing with the best intentions and not
understanding what the limited role of opiates is,I says $allantyne, now a professor of
anesthesiology and pain medicine at the University of /ashington. H.or 61 years they
have been taught that everybody deserves an opiate, because they really dont know
what else to do. Its a cultural thing and its hard to reverse that.I
In the !ime feature $allantyne continues5
HIn this country we e"pect everything to be fi"ed, and that doctors have the answer and
can take pain awayJ /e shouldnt be resorting to pills as a first resortK they should
very much be a last resortI
.ranklin, -. ;610A<. Opioids for chronic noncancer pain5 * position paper of the
*merican *cademy of +eurology Neurology, 83 ;0A<, 0699)068A ,OI5