Opioids for Chronic Pain?

Richard W. Rosenquist, MD

As ever more scrutiny is focused on the use of opioids in the United States, two principles should loom large in the minds of clinicians:

• The role of opioids in treating chronic pain is very small and limited to a narrow subset of patients
• Any plan to start a patient on opioids must include measurable treatment goals and a directive to stop using opioids if goals aren’t met.

Overcoming misjudgment from decades ago

But it wasn’t always that way. In the late 1980s, pain specialists tried to improve treatment of chronic pain by expanding the use of opioids. Opioids were known to be effective for acute pain, so the thinking was, “Why not use them for patients with chronic pain who needed greater relief?”

At the time, many pain specialists believed that if opioid use were limited to legitimate indications, patients would not become addicted. But reality caught up with us. We learned that people who get started on opioids have a much higher conversion to active addiction than previously thought. Also, physical dependence on opioids develops quickly — and in some people turns into physical addiction.

A steep societal toll

These lessons did not become clear for years, however, and the prescription of opioids surged during the 1990s and early 2000s. Opioid abuse increased in tandem. The consequences have been making headlines ever since:

• 15,000 to 18,000 U.S. deaths per year attributable to prescription opioid overdose
• The proliferation of (and later crackdown on) “pill mills” that spurred a subindustry, reselling opioids for profit
• Burgeoning rates of addiction to heroin, a less-expensive opiate that addicts turn to for cost reasons or when they can no longer access prescription opioids because of the pill mill crackdown

Other reasons to nix chronic opioids

These huge addiction-related costs are a major reason why the pain medicine community has dramatically scaled back the use of opioids for chronic pain. But it’s not the only reason.

Disappointing efficacy is another mark against the drugs. People originally thought opioids had no ceiling effect, but it turns out opioids don’t yield much pain relief in the chronic setting. After a while, patients are lucky to get 20 or 30 percent relief. Improvement of functional outcomes and general well-being is often even less.

Many patients on chronic opioids feel worse overall because of the drugs’ now well-established side effects, including immunosuppression, endocrine abnormalities, constipation, sedation and depression. Cruelest of all, some patients experience worsened pain — opioid-induced hyperalgesia.

Rare cases when opioids are indicated for chronic pain

So, when do we at Cleveland Clinic consider opioids for chronic pain conditions?

We commonly use them to treat cancer pain, either alone or in combination with other therapies. We’ll also consider them when there are medical contraindications to other choices for chronic non-cancer pain control. In those cases, we use opioids in low doses and aim to maintain a steady dose. In general, high doses are rarely successful.

Continued opioid use is contingent on demonstrated improvement in functional outcomes, not just pain scores. If you give an antibiotic for a UTI and it doesn’t treat the infection, you stop it. The same principle applies to opioids.

Today’s challenge: caring for displaced patients

Today we’re working harder to address the needs of patients who have endured longtime opioid use. It’s particularly important now that many unscrupulous providers have stopped prescribing opioids in the wake of regulatory crackdowns, leaving their patients desperate for new prescribers.

Cleveland Clinic’s Department of Pain Management has implemented a new approach for managing these displaced patients. The essence is simply evaluating a patient’s pain and opioid use and getting them to the right provider. Patients who have an addiction are referred to Cleveland Clinic’s Alcohol and Drug Recovery Center or its distinctive interdisciplinary Chronic Pain Rehabilitation Program. The latter is a comprehensive three- to four-week outpatient program designed to reduce both pain and chemical dependency and help patients foster coping skills and improved function.

Once addiction is addressed, we restart the patient’s pain management with a proper evaluation to uncover underlying causes of their pain. That typically leads to a multimodality treatment strategy that may include psychological approaches, interventional treatments, physical therapy and more.

We take them away from an unhealthy, pain-coping habit and introduce them to a “pain wellness program.”

Dr. Rosenquist is Chairman of Cleveland Clinic’s Department of Pain Management.