Title: Systematic Review: Opioid Treatment for Chronic Back Pain: Prevalence, Efficacy, and Association with Addiction.
Author: Bridget A Martell, Patrick G O’Connor, Robert D Kerns, William C Becker, Knashawn H Morales, Thomas R Kosten, David A Fiellin.
Source: Annals of Internal Medicine 2007;146(2):116-127.
Bridget Martell et al presented an ambitious, systematic review of the effectiveness of opioid therapy in the treatment of chronic back pain. The review is important since pain is the most common reason that patients enter the healthcare system, commonly through visits to physicians’ offices, presentation at emergency departments, or by visiting community pharmacies.1 Certainly opioids should not always be the first choice to treat chronic pain but neither should opioids be the last choice. Opioid therapy is based on primary care providers’ evaluation of the patient’s history, physical exam and judgment especially when a non-opioid treatment plan fails to lessen the pain. Pain, especially chronic pain, serves no positive physiologic value.2 With growing concern about prescription medication abuse and diversion, the question must be asked whether we as primary care providers are following the “Hippocratic Oath.”
The article asks three pertinent questions: 1) What is the prevalence of opioid treatment for low back pain? 2) Are opioid medications effective in treating chronic pain? and 3) What is the prevalence of substance use disorders among patients receiving opioid medications for chronic back pain? The methodology and rigor shown by the authors was truly impressive yet failed to answer these questions in a clinically meaningful way.
Most of the articles reviewed for prescribing opioids for chronic back pain involved specialty clinics, not primary care practices. This does not represent usual care of patients, as many if not most are treated by primary care clinicians. High variability of prescribing opioids was noted: 3%-33% in primary care practices and 11%-66% in specialty practices. The only conclusion that can be drawn is that some doctors prescribe opioids and others do not.
If opioids are effective, why do some doctors deny this option to patients? If opioids are not effective, why do some doctors use opioids with the risks and problems they can cause? The key question is “Are opioid medications effective in treating chronic pain?”
Each clinical trial included in the Martell analysis showed that opioids are more effective than placebo or the active comparator drug. Sample sizes were small, utilizing very heterogeneous designs and most studies were of short duration. These same trials that showed effectiveness of opioids were put in a meta-analysis and found not effective. The authors conclude: “the evidence in favor of opioids is not always consistent, and when supportive, only supports this treatment for short periods.” Lack of studies does not mean lack of effectiveness. A call for longer duration studies without discarding the treatment is a more appropriate conclusion.
The prevalence of substance use disorders among patients receiving opioid medications for chronic back pain is the most difficult question asked in the review. In clinical practice, doctors are often presented with patients who are suffering with persistent pain, who have failed multiple treatment trials including non-opioid medications, interventions, and referrals to specialists. The patients are so desperate for relief that they often spend their own resources pursuing complementary and alternative therapies. Does the article wish to address lifetime prevalence of substance use disorders in patients taking opioids for chronic low back pain or substance use disorders in the general population? The prevalence of addiction has been estimated as 3%-16%, most commonly cited as 10%.3 The article does not answer the question if drug abuse or addiction is higher or lower in the population with chronic back pain? The article also addresses aberrant medication-taking behavior under the same heading as prevalence of substance use disorders. Can pseudoaddiction or pseudotolerance be confused with labeling the patient with drug abuse or addiction, or chemical coping?4-6
A more important question for the practicing provider is: by placing a patient on an opioid, perhaps for years at a time, is harm being done? The article does not answer this question since the aberrant behaviors were not individually evaluated. The treating doctor wants to know whether prescribing opioids is improving the patient’s quality of life. The review correctly identified the poor quality of the studies looking at substance abuse in pain management. High prevalence of substance use disorders in patients with chronic low back pain on opioids does not predict what happens when a doctor is making a clinical decision with a specific patient who has failed multiple treatments and is suffering.
A review of the article leads the reader to believe that some doctors prescribe more opioids than others, that opioids do not work in long-term pain management, and that there is a high risk of substance abuse among treated patients. These conclusions, easily drawn after reading the article, would lead the prudent provider to stop prescribing opioids for chronic back pain patients. Is this the correct conclusion, supported by the article? Will this article result in the decreased prescribing of opioids, resulting in needless suffering and decreased quality of life of our patients with chronic back pain? In the absence of long-term quality studies, would it not be better to carefully evaluate the individual patient based on mutual trust and honesty and set appropriate boundaries before writing the first prescription for any controlled substance including opioids?7,8
References
- Glajchen, M, Chronic pain: treatment barriers and strategies for clinical practice. J Am Board Fam Pract, 2001;14(3):211-8.
- Oaklander, A., The pathology of pain. Neuroscientist, 1999. 5(5): p. 302-310.
- Savage SR. Long-term opioid therapy: assessment of consequences and risks. J Pain Symptom Manage. 1996;11(5):274-86.
- Weissman DE, Haddox JD. Opioid pseudoaddiction--an iatrogenic syndrome. Pain. 1989. 36(3):363-6.
- Pappagallo M., The concept of pseudotolerance to opioids. J Pharm Care Pain Symptom Control, 1998;6:95-8.
- Passik SD, Weinreb HJ. Managing chronic nonmalignant pain: overcoming obstacles to the use of opioids. Adv Ther, 2000;17(2):70-83.
- Heit HA, Gourlay D. Chronic Pain and Addiction. In Chronic Abdominal and Visceral Pain: Theory and Practice. Pasricha PJ, Willis WD, Gebhart GF, editors, NY. Taylor and Francis, 2006.
- Gourlay D, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-12
