September 30, 2014
The American Academy of Neurology (AAN) released a new position statement on opioid prescribing for noncancer pain [Neurology. 2014; DOI:10.1212/WNL.0000000000000839]. The organization said for mild to moderate pain conditions, such as headache, fibromyalgia, and chronic low back pain, the risks for overdose, addiction, or serious adverse effects associated with long-term use of opioids likely outweigh the benefits. For conditions like rheumatoid arthritis, sickle-cell disease, and neuropathic pain, AAN determined that the long-term risks of opioids are unclear.
When treating patients with chronic noncancer pain who continue to take opioids, doctors could use guidance on dosing, tools to screen for risks, and advice on how to monitor patients for early signs of adverse events and misuse, according to the study’s lead author, Gary Franklin, MD, MPH, research professor, departments of occupation and environmental health sciences, neurology, and health services, University of Washington, Seattle.
The statement follows a growing national epidemic of opioid-related deaths. Between 1999 and 2010, >100,000 Americans died due to opioid overdoses.
Opioid doses have increased dramatically and quickly during that period, according to Dr. Franklin. The average daily dose among a group of injured workers, for example, has gone from 80 mg per day to >140 mg per day.
Individual states are now responding to the urgent public health problem. For example, Washington, along with the Centers for Disease Control and Prevention, has "yellow flag" guidelines recommending that a prescriber seek consultation if a patient reaches 120 mg per day for morphine-equivalent doses without pain subsiding.
The Washington guideline has been updated to include tools for prescribing opioids to patients with chronic noncancer pain that allow clinicians to track pain and function, screen for past and current substance abuse and depression, and calculate daily morphine-equivalent doses in real time using a Web-based application.
A new Washington guideline, specific to workers' compensation, includes a tapering algorithm for patients receiving high doses who have not yet demonstrated meaningful improvement in function, and recommendations for perioperative opioid use in patients receiving chronic opioid analgesic therapy in whom elective surgery is planned.
Elsewhere, the FDA has implemented risk evaluation and mitigation strategies for extended-release and long-acting schedule 2 opioids. Just recently, the FDA has moved to reschedule hydrocodone products to schedule 2 rather than schedule 3 and to change labeling on extended-release/long-acting opioids to reserve their use for patients with more severe pain that requires around-the-clock dosing.—Kerri Fitzgerald