Paduda: Latest Research on Chronic Pain, Opioids and Other Drugs

Thursday, April 1, 2021 | 0

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.

Joe Paduda

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 [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 three to six months.

There was more credible research available to assess short-term outcomes versus longer-term outcomes, but 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 non-opioid 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 at longer (three to six months) versus shorter (one to three months) follow-up.

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.

Anecdotal evidence indicates some patients can do well on opioids for extended periods.

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, 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. 

Joseph Paduda is co-owner of CompPharma, a consulting firm focused on improving pharmacy programs in workers’ compensation. This column is republished with his permission from his Managed Care Matters blog.