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Studies Continue to Target Opioids and Their Alternatives in Chronic Pain Management

April 18, 2018
Focus on OUD sparks more research into the long-term effects of opioid therapy, tapers, and treatment referrals

The US Food and Drug Administration held a public discussion with patients and caregivers this past week about opioid use disorder (OUD). The meeting was held on the heels of announcements made by FDA Commissioner Scott Gottlieb, MD, and the Surgeon General regarding a renewed focus on OUD education and treatment, as well as on agency studies showing that fewer opioid analgesics may be necessary following certain procedures. For example, the agency noted that the average prescription for patients after laparoscopic cholecystectomy calls for 30 tablets while only one day of opioids may be needed to control pain after this common procedure.

Several research centers are trying to drill down to the core of this issue by examining the effects of opioid versus non-opioid therapy in managing chronic pain conditions, as well as OUD referrals and tapering protocols. One study out of the Minneapolis VA analyzed opioid and non-opioid pain treatment in patients with chronic back pain or hip/knee arthritis, concluding that “treatment with opioids was not superior to treatment with non-opioid medications for improving pain-related function over 12 months.”

The team, led by Erin Krebs, MD, MPH, of the Center for Chronic Disease Outcomes Research within the Minneapolis Veterans Affairs Health Care System, trialed 240 randomized patients (mean age: 58.3 years; women: 32 [13.0%]). They ultimately determined that their results did “not support initiation of opioid therapy for moderate to severe chronic back pain or hip or knee osteoarthritis pain.”

Medication Changes and Referrals

Travis Lovejoy, PhD, of the VA healthcare system in Portland, Oregon, has been pursuing similar research, reporting most recently that “patients who swap opioids for other therapies might not experience much difference with chronic pain.”   His team’s review of 600 veterans who had ceased or reduced opioid therapy still reported pain at levels comparable to those they had reported while relying largely on opioids. Reports were taken at 12 months prior to and 12 months after opioid therapy, with most of the patients having diagnoses of chronic musculoskeletal pain conditions.

“Clinicians should consider these findings when discussing with patients the risks of opioid therapy, as well as potential benefits of opioid tapering,” said Dr. Lovejoy in an OHSU release. His team recommended offering patients other ways to control the pain, including patient education about alternatives. 

In a related study  Dr. Lovejoy examined referrals for non-opioid pain care following a patient’s discontinuation of opioid therapy. Published in advance online, this study aimed to “compare rates of non-opioid analgesic pharmacotherapy initiation and clinician referrals for non-pharmacologic pain treatment" as well as for other types of complementary, integrative, and mental health or substance use disorder pain therapies, between patients discontinued from opioid therapy due to aberrant behaviors versus other reasons.

With a sample of 509 patients, the team concluded that there was a high variability in referral rates for different types of non-opioid pain treatments. Specifically, the authors observed that patients who discontinued opioid treatment due to aberrant behaviors, compared to patients who stopped opioids for other reasons, were more likely to receive opioid tapers, receive new non-opioid analgesics or dose changes to an existing non-opioid analgesic medication, or be referred to a substance use disorder specialist.

Access to OUD Treatment

One more VA Healthcare System study out of Portland, which included Dr. Lovejoy, explored access to and the history of OUD treatment. The team looked at treatment medication use such as methadone, buprenorphine, and injectable naltrexone, as well as barriers and facilitators to prescribing and medication receipt. They found that “there has been a slow but steady increase in the use of medications for OUD and, despite system-wide mandates and directives, uneven uptake across VA facilities and within patient subpopulations, including some of those most vulnerable.”  They recommended greater use of OUD medication going forward, in both the VA and beyond. 



Last updated on: April 19, 2018
Continue Reading:
FDA, AAPM Open Talks on Evidence-Based Opioid Prescribing
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