Original Article: Appropriate Use of Opioids for Chronic Pain [Lown Right Care]

Issue Date: September 15, 2020

See additional reader comments at: https://www.aafp.org/afp/2020/0915/p335.html

To the Editor: I disagree with Drs. Roth and Lazris that prescribing opioids for knee osteoarthritis pain in an older woman with chronic kidney disease is an appropriate use of opioids. Although abrupt discontinuation of chronic opioid therapy is medically and ethically inappropriate, continuing oxycodone for this indication is also not practicing evidence-based medicine.

A systematic review included 15 randomized controlled trials and 6,266 patients with osteoarthritis who were followed for 10 days to 24 weeks. Overall, 47% of patients taking opioids reported meaningful pain relief compared with 43% of patients taking placebo (number needed to treat = 32; number needed to harm = 8), with no differences in pain relief after four weeks.¹ A 2018 randomized controlled trial similarly found that opioids were not superior to nonopioid medications for osteoarthritis at 12 months, and patients taking opioids had more medication-related harms.²

Opioids relieve the withdrawal symptoms they create, but the long-term pain benefit is minimal. Patients often interpret opioid withdrawal as their underlying pain condition. Opioid-induced hyperalgesia and other harms, such as impaired cognition, falls, and overdose, increase with age.

We need to carefully, slowly, and compassionately taper many patients with noncancer pain off of opioids. Stanford's BRAVO (broaching the subject, risk-benefit calculation, addiction, velocity and validation, other strategies) method is effective for these discussions between patients and physicians.³ Clinicians should consider gradually tapering the opioids over nine to 12 months or transitioning to buprenorphine.⁴ Many patients without opioid use disorder have difficulty tapering. Buprenorphine is an effective, safer choice in these circumstances.⁵ Topical diclofenac, a front-wheeled walker with a seat, and an orthopedic consultation may also help relieve pain and improve function.

Patients and communities deserve better than the continued overuse of opioids masquerading as evidence-based practice.

In Reply: We thank Dr. Perez for his reply but disagree that prescribing opioids for knee osteoarthritis pain in an older woman with chronic kidney disease is “masquerading as evidence-based practice” and inconsistent with current Centers for Disease Control and Prevention (CDC) guidelines.¹ Since the publication of our article, the CDC released data highlighting that chronic pain affects 20.4% of adults, and 7.4% of adults have severe pain that limits life or work activities, with the highest impact in adults 65 years and older.²

Selecting the appropriate treatment for adults with chronic pain requires a systematic, patient-centered approach that involves shared decision-making. Integrative approaches, orthopedic consultation, the use of walking assistance devices, and nonopioid and adjuvant medications, are the cornerstone of therapy and should be first-line options for all patients with chronic pain.³ However, many nonopioid choices have limited evidence of benefit, contraindications, significant adverse effects, or limited effectiveness. When nonopioid modalities have not adequately controlled pain or improved functional status, use of opioids can be an effective and acceptable choice. A National Institutes of Health Pathways to Prevention Workshop consensus statement concluded that “patients, providers, and advocates all agree that there is a subset of patients for whom opioids are an effective treatment method for their chronic pain, and that limiting or denying access to opioids for these patients can be harmful.”⁴

We agree that the evidence for long-term benefits of opioid use is not strong; however, significant evidence for the safety and benefits of the judicious use of opioids in appropriate patients is compelling.⁵ The judicious use of low-dose opioid therapy (less than 50 morphine milligram equivalents), with careful monitoring and a continued risk-benefits analysis, is an appropriate and evidence-based approach to care.^1,4–6 The use of other approaches (e.g., nonopioid and adjuvant medications) should continue with the lowest effective dose of opioids. Tapering is indicated only in patients who have not shown a significant improvement in pain or functional status. Doses greater than 90 morphine milligram equivalents should be avoided unless the benefits clearly outweigh the risks and appropriate safety strategies have been implemented.^5,6

As the CDC states, chronic pain is a high-impact chronic condition associated with significant functional status limitations and patient distress. To assert that there is no role for opioids in treating chronic osteoarthritis pain is not evidence based.