CME: Opioid Use in Chronic Non-Cancer Pain

CME: Opioid Use in Chronic Non-Cancer Pain
Author Information (click to view)

Gary M. Franklin, MD, MPH

Medical Director
Washington State Department of Labor and Industries
Chair
Washington Agency Medical Director’s Group
Research Professor
Departments of Environmental & Occupational Health Sciences, Neurology, and Health Services
University of Washington

Gary M. Franklin, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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Target Audience (click to view)

This activity is designed to meet the needs of physicians.

Learning Objectives(click to view)

Upon completion of the educational activity, participants should be able to:

 

  1. Discuss best practices—and the need for them—included in the American Academy of Neurology’s position statement on the use of opioids in the management of chronic non-cancer pain.
  2. Explain what providers can do to help ensure appropriate use of opioids.

Method of Participation(click to view)

Statements of credit will be awarded based on the participant reviewing monograph, correctly answer 2 out of 3 questions on the post test, completing and submitting an activity evaluation.  A statement of credit will be available upon completion of an online evaluation/claimed credit form at www.akhcme.com/pwsept5.  You must participate in the entire activity to receive credit.  If you have questions about this CME/CE activity, please contact AKH Inc. at dcotterman@akhcme.com.

Credit Available(click to view)

AKH

CME Credit Provided by AKH Inc., Advancing Knowledge in Healthcare

Physicians
This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint providership of AKH Inc., Advancing Knowledge in Healthcare and Physician’s Weekly’s.  AKH Inc., Advancing Knowledge in Healthcare is accredited by the ACCME to provide continuing medical education for physicians.

 

AKH Inc., Advancing Knowledge in Healthcare designates this enduring activity for a maximum of 0.5 AMA PRA Category 1 Credit(s)™.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Commercial Support(click to view)

There is no commercial support for this activity.

Disclosures(click to view)

It is the policy of AKH Inc. to ensure independence, balance, objectivity, scientific rigor, and integrity in all of its continuing education activities. The author must disclose to the participants any significant relationships with commercial interests whose products or devices may be mentioned in the activity or with the commercial supporter of this continuing education activity. Identified conflicts of interest are resolved by AKH prior to accreditation of the activity and may include any of or combination of the following: attestation to non-commercial content; notification of independent and certified CME/CE expectations; referral to National Author Initiative training; restriction of topic area or content; restriction to discussion of science only; amendment of content to eliminate discussion of device or technique; use of other author for discussion of recommendations; independent review against criteria ensuring evidence support recommendation; moderator review; and peer review.

Disclosure of Unlabeled Use & Investigational Product(click to view)

This educational activity may include discussion of uses of agents that are investigational and/or unapproved by the FDA. Please refer to the official prescribing information for each product for discussion of approved indications, contraindications, and warnings.

Disclaimer(click to view)

This course is designed solely to provide the healthcare professional with information to assist in his/her practice and professional development and is not to be considered a diagnostic tool to replace professional advice or treatment. The course serves as a general guide to the healthcare professional, and therefore, cannot be considered as giving legal, nursing, medical, or other professional advice in specific cases. AKH Inc. specifically disclaim responsibility for any adverse consequences resulting directly or indirectly from information in the course, for undetected error, or through participant’s misunderstanding of the content.

Faculty & Credentials(click to view)

FACULTY DISCLOSURES

Keith D’Oria – Editorial Director
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
Gary M. Franklin, MD, MPH
Discloses no financial relationships with pharmaceutical or medical product manufacturers.
 
 AKH and PHYSICIAN WEEKLY’S STAFF/REVIEWERS

Dorothy Caputo, MA, BSN, RN- CE Director of Accreditation
Discloses no financial relationships with pharmaceutical or medical product manufacturers.

AKH planners and reviewers have no relevant financial relationships to disclose.

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Gary M. Franklin, MD, MPH (click to view)

Gary M. Franklin, MD, MPH

Medical Director
Washington State Department of Labor and Industries
Chair
Washington Agency Medical Director’s Group
Research Professor
Departments of Environmental & Occupational Health Sciences, Neurology, and Health Services
University of Washington

Gary M. Franklin, MD, MPH, has indicated to Physician’s Weekly that he has or has had no financial interests to report.

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The management of chronic non-cancer pain (CNCP)—defined as pain lasting beyond 3 months—has emerged as a significant challenge for healthcare providers throughout the United States. In recent years, some studies have suggested that opioids can be taken safely to manage several CNCP conditions for long periods of time and with few severe problems as long as they are well-selected. However, there is little specific guidance on the dosing of opioids for CNCP in any statutes, regulations, or clinical guidelines.

“Many pain specialists believe that the best way to manage CNCP is to increase the dose of opioids, a trend that has been increasingly prevalent throughout the U.S.,” explains Gary M. Franklin, MD, MPH. “But as this trend has continued, we’re seeing more frequent reports of deaths from accidental poisonings as well as problems with opioid abuse, dependence, and addiction. The CDC and other public health agencies have stated there has been an epidemic of opioid prescribing and adverse consequences from these practices since the late 1990s. Between 1999 and 2010, there were more than 100,000 opioid-related deaths in the U.S., which far exceeds the approximate 58,000 military casualties that the country endured during the Vietnam War.”

In the journal Neurology, the American Academy of Neurology (AAN) published a position statement, written by Dr. Franklin, to help physicians manage CNCP. The AAN is the first national professional medical association to adopt such a statement. “The evidence of harm associated with long-term opioid use is high while the evidence of effectiveness of this approach is low,” Dr. Franklin says. He notes that clinicians need to recognize this imbalance and weigh the risks and benefits when treating patients with CNCP (Figure).

Best Practices

The AAN statement lists several best practices that clinicians can use to improve their use of opioids in patients with CNCP (Table). Some of these practices include using opioid treatment agreements with patients, accessing data from state Prescription Drug Monitoring Programs (PDMPs) before prescribing opioids, and routinely screening for substance abuse and mental health issues (see full study).

According to Dr. Franklin, one of the most important best practices from the AAN statement is to avoid escalating the dose of opioids, especially when patients are not achieving adequate pain relief. “It’s unlikely that chronic use of opioids for routine pain conditions like headache, fibromyalgia, and lower back pain will be worth the risk over the long haul,” he says. There is little evidence supporting the use of opioids chronically for conditions like migraine or generalized pain.

For more severe conditions—including destructive rheumatoid arthritis, sickle-cell disease, or severe neuropathic pain, among others—the AAN position paper recommends that prescribers seek out specific guidance on dosing opioids safely and use publicly available tools to effectively screen patients for opioid-related risks. Physicians also need guidance on how to monitor patients for early signs of severe adverse events, misuse, or opioid use disorder.

Alternatives to using long-term opioids for CNCP include cognitive-behavioral therapy, graded exercise, spinal manipulation, and interdisciplinary rehabilitation. “If CNCP persists, we can’t abandon these patients when they seek help,” says Dr. Franklin. “We need to use alternative treatments to more effectively relieve pain rather than continue to increase the use and dose of opioids.” He adds that physicians should also judiciously taper patients off opioids after they have been using higher doses for long periods of time, particularly if they have experienced an overdose event or if there is no evidence that pain and function have substantially improved while on opioids.

A Call to Action

The AAN position paper calls for primary care providers (PCPs) to refer chronic pain patients to specialists if they are taking high daily doses of opioids. “Opioid therapy should be part of a multifaceted approach to pain management,” says Dr. Franklin. “PCPs are often at the forefront, but using a collaborative care model can improve efforts to reduce opioid-related ED visits and hospitalizations. There needs to be active engagement within the community to ensure that opioids are being used appropriately.”

Dr. Frankin says that several approaches may further help PCPs with the appropriate use of opioids, including the integration of best practices into electronic health records, use of pharmacist co-management, and more widespread use of specialty consults via telehealth. “Time will tell if these types of interventions can improve how clinicians use opioids to manage pain,” he says. “In the meantime, physicians can refer to the AAN position paper to find information on the best practices for opioid use in patients with CNCP. There are many tools available, but the key is to get physicians to integrate them into their daily practice.”

Readings & Resources (click to view)

Franklin GM. Opioids for chronic noncancer pain: a position paper of the American Academy of Neurology. Neurology. 2014;83;1277-1284. Available at: http://www.neurology.org/content/83/14/1277.full.

Vital signs: overdoses of prescription opioid pain relievers: United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487–1492.

Chou R, Ballantyne JC, Fanciullo GJ, Fine PG, Miaskowski C. Research gaps on use of opioids for chronic noncancer pain: findings from a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10:147–159.

Dunn KM, Saunders KW, Rutter CM, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152:85–92.

2 Comments

  1. I would give up my oxycodin I’m a heartbeat if they could find a cure for the daily nerve pain,migraines,and eposodic cluster headaches. After 5 years with out them I was ready to give up.

    Reply
  2. 10.01.2015
    As a neurologist with interest in headaches, I have read Dr. Franklin’s editorial in Neurology earlier this year and the opposing views by Dr. Stephen Nadeau in the same journal few months apart. Obviously the two neurologists belong to opposing camps, one somewhat narcophobic and the other more liberal, and my sympathies lies with the latter camp for the following reasons:
    Firstly, we learn by experience that pain is a miserable sensation that people want to avoid entirely even after a useful medication has been able to mitigate it for the most part.

    Secondly, opioids remained the safest and most effective remedy available to do the job. Thirdly, as indicated in the 2013 FDA response to the petition by PROP (physicians for responsible opioid prescribing) attribution of death to high dose opioid treatment is false and that there is no ceiling dose for opioid prescription; all depending on the patients’ response weather adverse or positive).

    Reply

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