Opioids and Chronic Pain Shifting Sands

This letter went out to Physicians at St. Joseph Medical Center August 27, 2014.   It’s a little long for a “blog” but here it is:

Opioids and Chronic Pain: Shifting Sand

The FDA has reclassified Hydrocodone from a Schedule III opioid to Schedule II and Tramadol has become schedule IV.  The use of opioid medication for chronic non-cancer pain remains the most controversial topic in pain management.  “Opioid” is the proper term for all medications natural and synthetic that have a narcotic action similar to morphine.       We now have a dizzying array of opioid medications available to treat physical pain.   Drugs vary in many ways, including onset, duration of action, opioid receptor preference and affinity.   Some available drugs are pure opioids such the schedule II opioids morphine, Hydromorphone Oxycodone and Fentanyl. Hydrocodone, which has only been available as a combination medication with acetaminophen and occasionally ibuprofen, has been available up until now as Schedule III.   Prescriptions for Hydrocodone as a schedule II will no longer be available with refills and can not be called in by phone.  

   In the last 20 years we have seen a pendulum swing. Prior to 1990 there were very few physicians who advocated for the use of opioids to treat chronic pain conditions.   That all changed in the 1990’s and 2000s when we saw a tremendous increase in the use of opioids for non-cancer pain.   Much of this was spurred by small clinical studies and many anecdotal reports describing efficacy. In addition, many physicians and nurses worked to make pain management a priority and advocacy groups also joined in lobbying for more liberal access to opioid pain medication.   The Federal Joint Commission pushed the issue by mandating pain management for hospital accreditation.   Big Pharma moved in and filled the need with more variety and promoted long acting, rapid acting and highly potent pain killers.    

 While many will point to the improvements in helping millions of suffering patients, the highly publicized bad outcomes and serious problems have made lots of headlines.   Addiction, fatalities, drug misuse, abuse, tolerance, physiologic and psychological dependence have increased in step with the increase in prescribing.   Bad prescribing, poor patient selection, lack of patient education and poor patient compliance to established plans are just a few of the causes for these bad outcomes.   The pendulum is swinging back and it seems physicians are less willing to prescribe opioids for patients with chronic pain.

 While pain advocacy groups talk about physician’s fears of personal prosecution as the cause for this reluctance to prescribe, I think there are more compelling reasons.   Most physicians that I talk to who are reluctant to prescribe opioids simply feel that risks out weigh benefits and it’s the wrong way to treat patients. They are also uncomfortable with the complexities of prescribing regimens, drug choice, follow-up and long term management issues.

Opioids remain important and valuable drugs.   They have great potential to provide improvement in quality of life and well being for properly selected AND properly managed patients.     What we have learned from the last 20 years is not surprising.   Opioids are dangerous drugs and can also cause harm.     This is no different from many other medication classes but the association with addiction places them in a clearly different category.   We are now also worried about Acetaminophen and liver failure, NSAIDs with GI, Renal and cardiovascular risks, and tricyclic antidepressant medications due to anticholinergic and sedating side effects.   As for opioids, we continue to study and learn more about best practice in prescribing these important drugs.   Ignoring them or refusing to use them denies many patients much needed relief from unrelenting pain.   We must continue to be vigilant and use caution in prescribing all these medications as we learn more.  

The reclassification of Hydrocodone and Tramadol will not eliminate problems and it will make it harder to initiate opioid therapy. It sends another message to physicians and patients alike that opioids are dangerous.     It will result in a decreased access to opioids for chronic pain.   Time will tell what this swing of the pendulum will bring for patients who suffer from intractable pain especially at time when many other treatments for pain are also under scrutiny.                  

RLM 8-27-2014