Dr Steve Feinberg pointed me to two studies conducted by the Agency for Healthcare Research and Quality on chronic pain, both systematic reviews [reviews of published studies of a specific topic]. One focused on opioid treatments for chronic pain, the other on non-opioid pharmacologic treatment.
The non-opioid research reviewed 190 studies, of which 185 were RCTs. Researchers concluded:
improvement in pain and function was small with specific anticonvulsants, moderate with specific antidepressants in diabetic peripheral neuropathy/post-herpetic neuralgia and fibromyalgia, and small with nonsteroidal anti-inflammatory drugs (NSAIDs) in osteoarthritis and inflammatory arthritis.
The takeaways include there are some benefits from some drugs, often dependent on the patient’s medical condition.
The opioid treatment for chronic pain study was based on a review of 162 studies; “115 randomized controlled trials (RCTs) [the gold standard of clinical research], 40 observational studies, and 7 studies of predictive accuracy.”
Note that for research purposes, chronic pain is described as pain that lasts more than 3 to 6 months.
There was more credible research available to assess short-term outcomes vs longer-term outcomes; there was no RCT comparing opioids to placebo for medium or longer-term periods.
Takeaways included (and these are direct quotes):
- There were no differences between opioids and nonopioid medications in pain, function, or other short-term outcomes
- Opioids were associated with small benefits versus placebo in short-term pain, function, and sleep quality.
- There was a small dose-dependent effect on pain, and effects were attenuated [reduced] at longer (3 to 6 month) versus shorter (1 to 3 month) followup.
Most concerning, “there is evidence of increased risk of serious harms that appear to be dose dependent” [the higher the dose, the greater the risk].
This crossed my desk the day before a good friend’s brother died of an apparent opioid overdose, adding a painful exclamation mark to the study’s conclusion.
Extensive research in Australia focused on long-term opioid use in patients with chronic non-cancer pain found that:
Despite limited evidence of efficacy, there has been a considerable increase in the long-term prescribing of opioids for chronic non-cancer pain in several countries
Here’s the thing; the research we do have clearly demonstrates the risk of opioids is high, and the benefits are limited. However, there isn’t near enough research on the efficacy of long-term usage of opioids for chronic pain.
That said, the evidence we do have suggests that overall, efficacy may be limited at best, and the risks are high. Fortunately more research on opioid efficacy and risks and chronic pain has already been funded.
What we cannot do is force patients off opioids; this is dangerous and unethical.
What does this mean for you?
Opioids have their place – but be very careful, especially when use is long-term. Life is precious.