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Still trying to figure out the proper use of opioids

New York State is considering a bill that

New York State is considering a bill that would limit patients seen in emergency rooms to getting no more than seven days of prescriptions, when there is a lack of proof that seven is less risky than nine or better than five. Credit: iStock

Only the uninformed would argue that global warming doesn’t exist, or that we are not amid an opioid-abuse epidemic.

Opioids have been a staple of pain relief for millennia. In the 1970s and early 1980s, there was a concern that their use, even for severe pain due to cancer, would lead to addiction. The so-called “opiophobia” led to the undertreatment of many patients. Not only were physicians reluctant to prescribe the needed medications, but a 1981 survey found that pharmacies often were unwilling to keep them in stock.

The misconception that physical dependence and psychological dependence — that is, addiction — are the same, led to some 30 percent to 50 percent of patients with terminal cancer dying in pain, many unnecessarily. In 1986, the World Health Organization released guidelines that stated, “If pain occurs, there should be prompt oral administration of drugs in the following order: nonopioids (aspirin and paracetamol); then, as necessary, mild opioids (codeine); then strong opioids such as morphine, until the patient is free of pain.”

A turning point seems to have occurred in the late 1980s and early 1990s. The principles used to guide pain treatment in patients with cancer were, with good intent, extended to the noncancer population. Between 1999 and 2014, prescriptions for opioid medications quadrupled despite a lack of related breakthroughs in science or education. The number of U.S. deaths from all opioid overdoses quadrupled in that period, surpassing the number of deaths from motor-vehicle accidents. Very recent data show the number of opioid prescriptions has dropped in the last couple of years, but there has been no associated drop in the number of all opioid-related deaths.

There has been a widespread and generally well-meaning outcry to stem this tide. In 2007, the American Pain Society and the American Academy of Pain Medicine published guidelines for opioid use in noncancer patients, and posed 37 key questions that needed to be answered, to guide doctors in making rational decisions about the use of opioids for noncancer pain. But after more than 200 pages, one of their major conclusions was that there is “very sparse” evidence to help devise ways to identify patients more likely to benefit from opioids and those more likely to experience adverse effects. The authors noted that doctors must understand both the principles of opioid prescribing and the risks associated with opioid abuse and addiction, but they concluded that reliable evidence is not available to estimate the incidence of aberrant drug-related behaviors in patients prescribed chronic opioids for chronic noncancer pain.

Guidelines issued by the Centers for Disease Control, the American Academy of Neurology and many other professional organizations are based primarily on literature reviews and expert opinion. While valuable, this level of evidence is insufficient to reliably inform clinical practice.

New York State is considering a bill that would limit patients seen in emergency rooms to getting no more than seven days of prescriptions, when there is a lack of proof that seven is less risky than nine or better than five.

Until we have reliable scientific data to guide our decisions, we sometimes have to rely on opinions that would not be considered sufficient to support treatment in other medical conditions. That said, our primary goal must be to care for patients in pain and to do our best to alleviate their suffering, while protecting them and the society from aberrant behaviors and abuse. Education of physicians and patients on the benefits and risks of chronic opioid therapy is essential, but that education must be grounded in firm data from well-conducted research and studies.

As St. Thomas Aquinas said, “Nothing is intrinsically good or evil, but its manner of usage may make it so.”

Ron Kanner is professor and chairman emeritus in the Department of Neurology at Hofstra Northwell School of Medicine.

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