I have read with interest the recent thoughtful editorials in The Rheumatologist about the future of rheumatology and our healthcare system in general. There is another problem affecting both the practice of rheumatology and primary care that is having a negative impact upon patient care, as well as on the careers of certain rheumatologists like myself. This problem concerns the overuse of prescription opioids for chronic non-cancer pain, including the rheumatic disorders—a practice which continues to grow with insufficient attention to the consequences. This has occurred irrespective of publications which confirm the importance of pain-relieving, non-drug therapies for most of the rheumatic disorders, as well as the pitfalls of opioid overuse for chronic non-cancer pain.1-4 Some of these beneficial strategies include education, self-help courses, physical therapy and exercise programs, and psychological and behavioral approaches to pain management.
Growth of Opioid Use
The main controversy involves the difference between selectivity in the use of opioids in chronic non-cancer pain for specific clinical indications versus non-selectivity for most types of chronic pain represented by the movement to expand the use of opioids beyond the pain of cancer. Selective instances in which opioids may be beneficial include intractable tissue-generated pain, such as that caused by nerve disease or damage or end-stage arthritis, especially in the absence of other options. However, the use of opioids in other types of chronic non-cancer pain, especially that of central origin, may increase risks while the benefits may be minimal. Examples include central pain sensitivity states such as fibromyalgia syndrome, especially if associated with co-morbid depression or anxiety states.
Over the last decade, an expansion in the use of opioids has been advocated by certain pain specialists as well as pharmaceutical companies. In my opinion, this has occurred in the absence of valid data that support the claims that opioids can effectively and safely be extended beyond cancer to most patients with chronic non-cancer pain with a low risk of addiction. Such claims have subsequently been found to be inaccurate, and the original statement about the low rate of addiction to a common oxycodone sustained-release formulation has been shown to be false (as recently admitted by pharmaceutical company executives as a result of a Federal indictment).
Recent reviews confirm the absence of reliable long-term randomized controlled trials that demonstrate the efficacy and safety of opioid therapy for chronic non-malignant pain for more than eight months.5-7 Further, in addition to increasing the risk–benefit ratio, over-reliance on long-term opioid therapy in rheumatic disorders may impede the learning of important self-efficacy and self-management skills that enhance favorable therapeutic outcomes with less dependence upon pain-relieving drugs.
Unfortunately, the non-selective and widespread use of prescription opioids, as well as illicit non-medical misuse, have contributed to a mounting toll of documented adverse events which were just starting to be recognized six years ago. This includes the high incidence of abuse and diversion, the substantial risk of addiction, the growing problem of opioid-related crime, the increased availability and ease of access to opiate drugs by teenagers and young adults (who misperceive prescription drugs to be safe), and the soaring statistics of emergency department visits, overdose, and death.8