FROM THE SOCIETY OF GENERAL INTERNAL MEDICINE
Christina Nicolaidis, MD, MPH
TORONTO—The majority of patients with chronic pain are managed by primary care physicians, most of whom have little training in pain medicine. Effective pain management requires a familiarity with pain medicines and their appropriate use, along with their potential for aberrant use.
Opioids are often prescribed for the treatment of chronic noncancer pain. Although they appear effective for short-term pain relief, their long-term efficacy is unclear, said presenters at the Society of General Internal Medicine annual meeting.
"Recent concerns about nonsteroidal antiinflammatory drugs [NSAIDs] may lead to increased use of opioids," said Daniel Alford, MD, MPH, associate professor of medicine, University of Boston.
For chronic low back pain, the evidence supports the value of opioids in relieving pain for up to 4 months, but long-term trials are lacking, he said.
For chronic noncancer pain (ie, nociceptive or neuropathic pain and fibromyalgia), opioids have been shown to decrease pain and improve function compared with placebo, but only the strong opioids are better than NSAIDs or tricyclic antidepressants for that purpose.
In a Danish national survey of patients with >6 months of chronic noncancer pain, "opioids did not meet any of the key outcome long-term treatment goals: pain relief, improved quality of life, and improved functional capacity," said Karina Berg, MD, assistant professor of medicine, Albert Einstein College of Medicine, New York City.
Until better evidence is available on efficacy and outcomes, Dr Berg therefore advises cautious use of long-term opioid therapy for patients with chronic pain.
Up to one fourth of patients who receive opioids for chronic back pain exhibit aberrant medication-related behaviors that may be interpreted as signs of abuse, said Matt Bair, MD, assistant professor of medicine, Roudebush VA Center of Excellence for Implementation of Evidence-Based Practice, Indianapolis.
Furthermore, no longitudinal, randomized, controlled trials have been conducted to determine whether the long-term effects and consequences of opioids for pain relief are beneficial or harmful, said Dr Bair.
To address potential opioid abuse, many physicians have been entering into "opioid contracts" with patients who are prescribed opioids for chronic nonmalignant pain. These contracts lay out the rules and expectations up front for access to a potentially controversial therapy that the patient and physician agree is a reasonable risk to take. For such contracts to be effective, deviations from the agreement must be confronted and addressed with action.
"Although many professional groups recommend pain management contracts, there are no strong data to support their use," said Dr Bair.
Physicians must be vigilant about monitoring for aberrant behaviors that indicate that the patient is diverting his medications. Routine urine toxicology can help in this regard, looking for an absence of the prescribed medication. Also, be wary of new patients with stories that do not seem believable, those with strange symptoms, and those with specific drug requests.
Physicians need to communicate that they take the patient's pain seriously, said Christina Nicolaidis, MD, MPH, assistant professor of medicine and public health, Oregon Health and Science University, Portland.
Before prescribing a pain medication, "discuss the possible functional benefit that the patient anticipates from initiating or changing narcotics," she said. "Ask the patient what he or she expects to do with the treatment that he or she can't do now."
Continuation of any medications will depend on whether or not a clear benefit is observed, and goals and benefits should be assessed at regularly scheduled follow-up visits. Dr Nicolaidis recommends following up every 1 to 3 months for these assessments.
The possible risks of the medication should be discussed, including the potential for dependence and addiction. "Assign responsibility to the patient to look out for early signs that the medications may be harming him or her," she said.
Prescriptions for pain medications should be timed to patient visits and never refilled over the phone or refilled early. Patients should consent to urine drug tests to monitor for harm.
If no benefit is observed with the medication, "stress how much you believe and empathize with the patient's pain severity and its terrible impact," Dr Nicolaidis advised.
If a patient has breached his contract with regard to his pain medication use, your concern for addiction should be raised. Withdrawing the medication in this instance may make for an unpleasant visit, she said, but the benefit–risk ratio of the medicine needs to be reinforced.