Pain Management and the Opioid Epidemic Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use (2017) / Chapter Skim
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2 Pain Management and the Intersection of Pain and Opioid Use Disorder
2 Pain Management and the Intersection of Pain and Opioid Use Disorder
Pages 49-118
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From page 49... ...
The first section summarizes the scope of the problem of pain, focusing in particular on chronic, or persistent, pain, the form most associated with problematic use of opioids. The chapter then presents a detailed discussion of the various pain treatment modalities, reviewing in turn opioid analgesics, nonopioid pharmacologic treatments, interventional pain therapies, and nonpharmacologic treatments.
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From page 50... ...
. Chronic noncancer pain also has been found to be associated with work absenteeism (Agaliotis et 1 Survey participants were asked whether they had ever had "arthritis or rheumatism" in their lifetime.
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As discussed below, opioids have long been used for the effective management of acute pain (e.g., acute postsurgical and postprocedural pain) , but available evidence does not support the long-term use of opioids for management of chronic noncancer pain.
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From page 52... ...
Yet pain management may involve the use of a n umber of tools -- both pharmacologic and nonpharmacologic -- to relieve pain and improve function and quality of life. Before proceeding to a review of these various treatments, it should be noted that, while each may be used on its own, their integration in multimodal strategies that cut across medical disciplines and incorporate a full range of therapeutic options -- including ognitive-behavioral, physical/rehabilitation, pharmacologic, and c interventional therapies -- has been shown to be most effective in the treatment of chronic pain (Koele et al., 2014; Scascighini et al., 2008)
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It is significant, then, that many of the nonpharmacologic techniques are reimbursed poorly if at all by third-party payers, creating a disincentive to provide this effective care for patients. See Chapter 5 for further discussion of policies regarding reimbursement of comprehensive pain management.
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From page 54... ...
) in chronic noncancer pain found that "all patients with CNCP [chronic noncancer pain]
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. Accordingly, some of the most difficult patients for whom to provide pain relief are those with end-stage liver or kidney disease or with bleeding disorders, many of whom end up taking opioids chronically because of the perceived paucity of effective alternatives.
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Addressing this question is challenging given the lack of a single integrated source of information on the use of prescription opioids in the United States. This is the case despite calls from both governmental and nongovernmental organizations for improved methods for tracking and accountability of opioid prescribing practices, indications, efficacy, or disposal and the more than decade-long development of the opioid epidemic.
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In 2012, the rate of opioid prescribing among specialists was highest for specialists in pain medicine (48.6 percent) , followed by surgery (36.5 percent)
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In these situations, limited supplies of opioids may be prescribed by emergency departments, urgent care clinics, specialty physicians, and primary care providers. The prescribing of opioids by emergency departments has been especially closely studied, and an increase was found to coincide with an increase in overall opioid prescribing (Maughan et al., 2015)
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. Given the widespread use of opioids for noncancer pain and the fact that individuals with musculoskeletal disorders, including arthritis, represent the largest population using prescription opioids, understanding the factors driving opioid use among these individuals could shed light on the broader landscape of prescribing practices.
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In a study of veterans treated in a regional health care network for chronic noncancer pain, for example, factors associated with use of high-dose opioids (>180 milligrams morphineequivalent dose) , after controlling for demographic factors and facility, included low back pain, neuropathy, and nicotine dependence.
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examining the pattern of opioid use 6 months before and after an index visit for back pain, 61 percent of the 26,014 eligible patients had received a course of opioid therapy, and 19 percent had become long-term (≥120 days or >90 days with 10 or more fills) opioid users.
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Moreover, studies examining the results of urine drug screens from patients with cancer and in palliative care have provided significant evidence of opioid misuse and diversion (Barclay et al., 2014; Childers et al., 2015) , while many cancer pain and palliative care clinics lack formal policies addressing drug misuse and diversion (Tan et al., 2015b)
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Therapy with opioids following third molar extraction or other oral surgery procedures may be indicated as it does provide adequate pain relief (Weiland et al., 2015)
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Importantly, in 2016 the Centers for Medicare & Medicaid Services issued a proposed rule to remove posthospitalization patient survey questions about pain management from scores that are tied to Medicare
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From page 65... ...
In addition, a tension exists between efforts to curtail prescribing and the interests of at least some groups of patients in maintaining access to opioids. Many of the recommendations commonly discussed in considering opioids for the management of chronic noncancer pain are encapsulated in the so-called universal precautions of pain medicine (Gourlay et al., 2005)
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Regularly Assess the "Four As" of Pain Medicine: Analgesia, Activity, Adverse Effects, and Aberrant Behavior 9. Periodically Review Pain Diagnosis and Comorbid Conditions, Including Addictive Disorders 10.
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Guideline for Prescribing Opioids for Chronic Pain (see Chapter 5) recommends that patients who have been on high dosages of opioids "be offered the opportunity to re-evaluate their continued use of opioids at high dosages in light of recent evidence regarding the association of opioid dosage and overdose risk" and that providers review the risks and benefits of continued opioid therapy with these patients (Dowell et al., 2016, p.
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From page 68... ...
Given the limited number of pain specialists, primary care providers play an essential role in pain management and in overcoming the challenge of undertreatment of pain (IOM, 2011)
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(The section on clinical research in Chapter 3 includes discussion of improving pain management in the primary care setting despite a relative lack of access to pain specialists, while the discussion of Project ECHO in Chapter 4 describes a model for providing high-quality care through expert teleconsultation with community providers.) Summary Opioids are widely prescribed in a variety of settings for treatment of both acute and chronic pain, frequently including back pain, pain due to arthritis and other musculoskeletal conditions, and dental pain.
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70 PAIN MANAGEMENT AND THE OPIOID EPIDEMIC supporting the practice, however, providers continue to prescribe opioids for extended periods. NONOPIOID PHARMACOLOGIC TREATMENTS Nonsteroidal Anti-Inflammatory Drugs NSAIDs are commonly used to treat acute pain following trauma or interventional procedures, as well as pain due to some chronic inflammatory musculoskeletal conditions, such as arthritis.
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. And a systematic review comparing oral NSAIDS with opioids for treatment of pain due to knee osteoarthritis over at least 8 weeks' duration found similar pain relief for both analgesics (Smith et al., 2016b)
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, the analgesic effect of antidepressants is separate from their effect on depression. Pain relief occurs at lower doses than doses with an antidepression effect (Hameroff et al., 1984; Langohr et al., 1982; Magni, 1991)
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. Mechanistically, the goal of these agents is to suppress the sensation of peripheral neuropathic pain, described as arising from both unmyelinated C-type (slowly conducting)
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More recently, gabapentin and pregabalin have been emerging in a widening range of applications initially considered "off-label," including as single or part of multimodal therapies for perioperative pain management (Chaparro et al., 2013) , opioid-sparing strategies and reduction of the risk of opioid-induced hyperalgesia (Stoicea et al., 2015)
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. When such low-dose capsaicin preparations have been studied or compared with so-called first-line neuropathic pain treatments using a grading system requiring multiple RCTs, they typically have not provided robust neuropathic pain relief and showed poor to moderate efficacy in the treatment of either musculoskeletal or neuropathic symptoms (Attal et al., 2006; Mason et al., 2004)
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is now linked to inflammatory and neuropathic pain, the blockade by local anesthetics represents a plausible mechanistic approach to treatment of chronic pain (Waxman et al., 1999)
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. Accordingly, epidural/ spinal clonidine has been approved for infusion in the treatment of cancer/ neuropathic pain that is refractory to opioid analgesics (Hassenbusch et al., 2002)
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are released from the central terminals of primary afferent nociceptors onto spinal neurons expressing NMDA receptors. Under persistent nociceptive pain and activation of C-type nociceptors and in turn, activation of ionotropic NMDA receptors, changes occur in neuronal plasticity at the nociceptive processing center of the spinal cord -- the dorsal horn (Li et al., 1999)
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From page 79... ...
have been cloned. CB1 is present in the brain, the spinal cord, and the peripheral nervous system, as well as in a number of neuronal tissues, including the liver, skeletal muscle, and the gastrointestinal tract; most of its analgesic effect is mediated by the CB1 receptor.
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From page 80... ...
They can be taken in herbal form, extracted naturally from the plant, or manufactured synthetically. Recent systematic reviews and meta-analyses have found evidence to support the use of cannabinoids for the treatment of such chronic pain conditions as neuropathic pain, cancer-related pain, fibromyalgia, and HIV-associated neuropathy (Lynch and Ware, 2015; Whiting et al., 2015)
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From page 81... ...
Nonopioids such as cannabinoids and ketamine, which have shown promise for relief of some forms of pain in some pain management settings, also have potential adverse side effects. In cases of opioid tolerance, α2 androreceptor agonists can provide improved analgesia and help reduce signs and symptoms of opioid withdrawal.
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. Types of Interventional Pain Therapies Epidural steroid injections are the most commonly performed interventional pain therapies (Manchikanti et al., 2012)
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Spinal cord stimulation (SCS) has expanded in scope in recent years, from being utilized mainly for neuropathic pain related to painful postlaminectomy pain syndrome or failed back surgery syndrome to being applied for other neuropathic, sympathetic, vascular, and even visceral pain syndromes (Deer et al., 2014)
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. Complications of interventional pain management are multifactorial and are related to issues including performance of the procedure, patient anatomy, and comorbidities.
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. A 2014 systematic review of massage therapy for fibromyalgia pain found that massage therapy of at least 5 weeks' duration resulted in significant improvement in pain, anxiety, and depression.
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. However, there are a number of barriers to the successful use of exercise therapy for pain management.
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CBT has been shown to be effective in managing chronic pain, either on its own or together with other pain management tools, such as medication. Over the past half century, evidence has accrued that the experience of pain is not based solely on sensory or neurologic states but is influenced by cognitive and affective processes (Ehde et al., 2014)
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From page 88... ...
A meta-analysis of 38 RCTs of various forms of mindfulness meditation intervention for chronic pain management found that mindfulness improved pain, reduced symptoms of depression, and improved quality of life compared with treatment as usual, support groups, education, stress management, and waitlist controls (Hilton et al., 2017)
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They suggest that these findings may foster greater acceptance of meditation as an adjunct pain therapy. Taken together, this emerging body of work suggests that the practice of mindfulness meditation for pain management may be promising.
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Placebo analgesic response is the result of this phenomenon. Consistent placebo analgesic effect has been demonstrated in dental pain, postthoracotomy pain, low back pain, irritable bowel syndrome, neuropathic pain, and experimental pain (Enck et al., 2008; Finniss et al., 2010; Kaptchuk and Miller, 2015; Price et al., 2008)
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From page 91... ...
While further research is needed to better understand the mechanism of action and the appropriate dosage and delivery for some nonpharmacologic approaches, they may provide effective pain relief for many patients in place of or in combination with pharmacologic approaches. DIFFERENCES IN PAIN EXPERIENCES AND TREATMENT EFFECTIVENESS AMONG SUBPOPULATIONS Part of the committee's charge was to review the available evidence on differences in the experience of pain and the effectiveness of treatments across subpopulations.
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From page 92... ...
. A review of 18 studies showed lower opioid consumption postoperatively among women than men, but this finding has not been consistent, may depend on the type of procedure performed, and may reflect increased prevalence or reduced tolerance of side effects from opioids in women rather than less need for pain relief (Miaskowski et al., 2000)
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From page 93... ...
Some research indicates that blacks are less likely than non-Hispanic whites to receive an opioid for chronic noncancer pain (Cintron and Morrison, 2006; Dickason et al., 2016; Ringwalt et al., 2014, 2015) , and this disparity appears to be more common in some specialty settings than in others (Ringwalt et al., 2014)
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From page 94... ...
. Telemedicine/Internet-based technologies are one approach that has been used to bridge geographic distance to improve the quality of pain care in communities with limited access to providers with expertise in pain management (Currie et al., 2015; Eaton et al., 2014)
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The percentage of such patients in a treatment population is dependent on such risk factors as younger age and higher overall opioid dosage (Palmer et al., 2015)
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Furthermore, recent research (Blanco et al., 2016) shows that persistent pain may lead individuals to use prescription opioids in patterns different from what their prescribing physician initially intended, resulting in opioid misuse or OUD.
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2010. Pain management: Part 1: Managing acute and postoperative dental pain.
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Cochrane Database of Systematic Reviews 12:CD010884. Butler, S.H., Weil-Fugazza, J., F
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2009b. Opioids for chronic noncancer pain: Prediction and identification of aberrant drug related behaviors: A review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline.
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for acute postoperative pain. Cochrane Database of Systematic Reviews 6:CD010210.
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for chronic neuropathic pain in adults. Cochrane Database of Systematic Reviews 2:CD007393.
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2015. Pharmacotherapy for neuropathic pain in adults: A systematic review and meta-analysis.
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Pain Management 6(4)
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2016. The opioid epidemic and the long term opioid therapy for chronic noncancer pain revisited: A transatlantic perspective.
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Presentation to the Committee on Pain Management and Regulatory Strategies to Address Prescription Opioid Abuse, Washington, DC. September 22.
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2011. Canadian guideline for safe and effective use of opioids for chronic noncancer pain: Clinical summary for family physicians.
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2015. Pain management in cancer survivorship.
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2001. Pain management: The fifth vital sign.
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2010. Chronic noncancer pain management and opioid over dose: Time to change prescribing practices.
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2013. Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental prac tice.
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Cochrane Database of Systematic Reviews 10:CD007753. Palmer, R.E., D.S.
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2014. Pain management with intrathecal clonidine in a colon cancer patient with opioid hyperalgesia: Case presentation.
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2014. Differential prescribing of opioid analgesics according to phy sician specialty for Medicaid patients with chronic noncancer pain diagnoses.
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Techniques in Regional Anesthesia and Pain Management 18(4)
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2012. Primary care providers' views on chronic pain management among high-risk patients in safety net settings.
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Cochrane Database of Systematic Reviews 6:CD007938. Williams, A.C., C
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Cochrane Database of Systematic Reviews 10:CD004311. Zwisler, S.T., J
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