Special Report: Chronic Noncancer Pain—Long-Term Opioid Benefits and Harms
Chronic noncancer pain (CNCP) is pervasive, with a large segment of the U.S. population experiencing unrelieved or inadequately treated pain. Opioids are one option for treating CNCP and have been increasingly used in recent decades. However, there is substantial uncertainty regarding long-term effectiveness, as well as the balance of benefits and harms. To provide focused reviews and perspectives of evidence concerning: 1) undertreated pain with emphasis on CNCP, and 2) the effectiveness, direct and indirect harms, and uncertainties accompanying opioid treatment of CNCP. A focused literature search was performed to identify relevant evidence, and a recent Institute of Medicine Report was also reviewed. Other sources reviewed included transcripts and videos of pertinent presentations and government hearings. Chronic pain is often unrelieved and undertreated and a significant patient and public health concern with substantial costs. Many interventions hold potential benefit for CNCP including pharmacologic, and nonpharmacologic (interventional and multidisciplinary/interdisciplinary rehabilitative). Opioids have been shown to be effective for short-term pain relief. However, when used long-term for CNCP and compared to other interventions, evidence to clearly define the net clinical benefit (balance of benefits and harms) and functional outcomes is lacking. The burden of opioid-related harms has increased substantially in recent decades. Harms affect both treated patients and spread or spillover to individuals of all ages—from nonmedical use in adults and adolescents to neonates experiencing abstinence syndrome or suffering from birth defects. In 2009, there were 14,800 deaths attributed to prescription opioids—representing a 3.7-fold increase over a decade. Existing guidelines recommend using opioids for CNCP in patients with inadequate response to non-opioid alternatives. However, achieving a favorable balance of benefits and harms in the setting of CNCP requires prescribing informed by the best available evidence. Providing patients suffering from chronic pain with effective treatment is an important goal, and many interventions are available. Opioids are but one alternative and one accompanied by potential harms to patients and others. Given the experience with opioids, effectively relieving pain, improving function, and minimizing harms in patients with CNCP will require concerted and coordinated efforts of health care providers, regulatory authorities, the public and payers, together with patients.Executive Summary
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abuse; acetaminophen; addiction; adverse effects; amitriptyline; anticonvulsants; aspirin; behavioral therapy; benefit; buprenorphine; capsaicin; carbamazepine; chronic pain; CII; cognitive; comparative effectiveness; consensus; controlled substance; dependence; diclofenac; discectomy; diversion; diversion; EHR; electrical stimulation; electronic health record; evidence based; exercise; fatalities; fentanyl; gabapentin; guidelines; harm; headache; hydromorphone; ibuprofen; implantable electrodes; Institute of Medicine; interdisciplinary; intravenous; IOM; oxycontin; lidocaine; methadone; migraine; misuse; MSContin; multidisciplinary; musculoskeletal; naltrexone; neuropathic pain syndromes; nonpharmacologic; nonsteroidal anti-inflammatory drugs; NSAIDs; opiates; opioids; oral; osteoarthritis; overdose; oxycodone; oxycodone; oxymorphone; pain; parenteral; patch; patches; PDMP; physiotherapy; prescription drug monitoring programs; psychotherapy; radiculopathy; rehabilitation; REMS; Risk Evaluation and Mitigation Strategies; spillover effects; SR; sustained release; systematic reviews; tapentadol; TENS; transdermal; tricyclic antidepressants;
