New treatment guidelines address chronic pain

The evidence-based recommendations focus on opioid use for non-cancer pain.

By Kevin B. O’Reilly — Posted Feb. 26, 2009

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For the first time, the country's two leading professional organizations devoted to pain medicine jointly released comprehensive guidelines for physicians using opioids to treat patients with chronic non-cancer pain.

The recommendations, published in the Feb. 6 Journal of Pain, are intended to help doctors navigate the tricky terrain of caring for the estimated 9% of Americans living with severe chronic pain while averting recreational use and diversion (link).

Meanwhile, the Food and Drug Administration announced plans to work with manufacturers of 24 long-release opioids to develop a single plan to manage the risk of opioid misuse and overdoses. The plan could include some sort of education requirement for doctors prescribing these opioids.

A national multidisciplinary group of doctors, ethicists and other experts from the American Academy of Pain Medicine and the American Pain Society took two years and reviewed 8,000 studies to produce the new guidelines. Among the recommendations, the expert panel said physicians should:

  • Discontinue opioid therapy in patients who are diverting their medications or displaying "serious aberrant behaviors," such as purchasing drugs on the black market, borrowing from other patients or increasing doses on their own.
  • Not set a cap on opioid dosage, but regularly monitor patients who need morphine-equivalent doses of 200 mg or more daily and consider rotating pain drugs when patients experience adverse effects or see little benefit.
  • Only use urine drug screens with patients who have engaged in "aberrant drug-related behaviors."

"The guideline [set] really does try to recognize that there is a balance we have to achieve in prescribing opioids and mitigating suffering while limiting all the risks associated with opioids," said Roger Chou, MD, lead author of the guidelines and scientific director of the Oregon Health & Science University's Evidence-based Practice Center. "Clinicians who prescribe these drugs have the responsibility to manage these risks and tailor their care management plan appropriately."

Dr. Chou said large gaps remain in medical research on proper opioid prescribing, and that many of the recommendations are based more on a consensus of expert opinion than high-quality evidence. The guidelines are in line with the Federation of State Medical Boards' 2004 model policy on using controlled substances to treat pain, said panel member Aaron M. Gilson, PhD, director of the University of Wisconsin Pain & Policy Studies Group.

FDA targets overdoses

The FDA is set to meet March 3 with makers of opioids such as fentanyl, methadone, morphine and oxycodone to devise a single "risk evaluation and mitigations strategy." The opioids, prescribed 21 million times in 2007, are driving a decade-long jump in accidental narcotics overdoses, the FDA said. The complete list of affected drugs is available at the FDA Web site (link).

"Our focus is going to be making sure that the prescribers are educated and understand the risk associated with these products and the appropriate patient population that should receive these products," said John Jenkins, MD, director of the Office of New Drugs at the FDA Center for Drug Evaluation and Research.

Dr. Jenkins said the FDA continues to see reports of physicians prescribing long-release opioids to patients who do not have chronic pain or who have not built a tolerance to the drugs.

Gilson worried about the initiative's potentially chilling effect on doctors' willingness to prescribe opioids.

"To require [education] for practicing professionals, it's difficult to anticipate what the consequence of that mandate will be," he said.

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