Long-term opiod use and chronic pain

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It is popular these days to be of the opinion that it is dangerous to use opiates for numerous reasons to treat chronic pain, especially in the long-term. Partially there is the risk of addiction although clearly not everyone gets addicted. Partially there is some basis that under certain conditions the treatment with opiates can increase pain sensitivity over time. And then with conditions like migraines, specifically, there is always the added issue that treatment with painkillers over and above three times a week could cause rebound headaches and if done too much migraine overuse headaches. So it is a complex set of issues and the stigma around it is pretty intense. I mean, I would be rather insulted if someone were to imply I would get addicted to painkillers automatically.

So this study Pain Patients can have Good Outcomes with Long-Term Opiate Treatments is pretty brave to imply anything against the stigma tide I think. Long-term opioid treatment “can produce positive outcomes in chronic noncancer pain when physicians prescribe it carefully to individuals who have low risks for addiction and overdose, according to the results of a systematic review.” (Pain Medicine News)

Essentially the study was a meta-analysis of past studies focusing on quality of life (QOL)

The researchers ” performed a meta-analysis of pre–post results on eight randomized controlled trials, eight open-label extension studies from randomized controlled trials and nine observational controlled studies. These 25 studies included 4,719 patients, 3,160 of whom (67%) completed the studies. The analysis focused on these latter patients.
The investigators found that long-term opioid use resulted in significantly improved function, and physical and mental QOL.” (Pain Medicine News)

She said that, for publication, the paper will include an uncertainty analysis that takes into account the worst-case scenario of a high dropout rate and the resulting underestimates of complications and overestimates of opioid effectiveness. Dr. Furlan also conceded that the patients in the systematic review represented a minority of typical chronic pain patients, because they did not have risk factors and were monitored carefully.
“It is true that most of these conditions are not followed in real-life opioid prescribing. [In clinical practice] I see a lot of careless prescribing, which can be characterized as ‘high-risk patients’ and/or ‘high-risk prescriptions.’ When you mix both, it is dangerous,” Dr. Furlan said in an interview with Pain Medicine News. “But when physicians and their teams take the time to carefully screen patients, keep them on as low a dose as possible and monitor them very regularly, our results show that the outcomes can be very satisfactory.”(Pain Medicine News)

I think quality of life should be a factor in this equation and it is often something that doctors can miss especially when they are focused on the biases associated with the types of medications available to treat their patient’s pain. This is not to say there are not medication alternatives for a doctor to consider in every situation. But you have to be quite moronic to believe such things as NSAIDs carry no risks to a patient… in fact, they have quite the death and ER record themselves, but because it is not Addiction we are talking about apparently it is fine. I will tell you I was not too pleased when my doctor at the time ignored my side effects due to NSAIDs because she was reluctant to prescribe anything else, resulting in a bleeding ulcer and so far permanent NSAID drug sensitivity.  And there are more than a few people for various reasons who cannot take NSAIDs due to the risks they have. So a doctor must carefully consider all medications and all risks. And I think when it comes to pain management he or she should be monitoring all medications, side effects and effectiveness in order for that person to have an effective treatment.

While I do not believe pain management is all about the medication I do believe it has a role. And I am a little tired of the stigma applied to opiates when they also have a role with some patients and their long-term chronic pain management. It does patients a real disservice if their doctors do not properly consider all possible treatments, whether for that patient it includes opiates or not. Obviously, in some cases, it will not. In some cases other medications are better suited. Because, as I said, it is about the quality of life. Quality of life can be completely unable to function, a hermit, unable to work and not coping with the pain…. or it can be something better than that. We all want something better than that and I think we deserve that.



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