Neurology Academy’s Opioids Stance Renews Access Debate

By Amanda Conschafter, blog editor

A new position paper by the American Academy of Neurology has incited renewed debate on opioid analgesics. But “Opioids for noncancer pain,” published in the academy’s official journal, has also stirred concerns about whether reform efforts target abusers at the expense of patients with legitimate medical need.

Authored by Gary M. Franklin, M.D., the academy’s paper addresses the “public health epidemic” of prescription opioid-related deaths.   The paper concludes that evidence supports short-term treatment of pain with opioids but cites a dearth of evidence on using opioids to treat noncancer pain over the long term. The ends do not justify the means, the paper concludes – but they do increase the risk of abuse, dependence and addiction.

The paper offers concrete suggestions for how physicians can curb abuse. Franklin posits screening pain patients for depression and drug abuse, drawing up an “opioid treatment agreement,” and conducting random urine tests on patients. The paper also urges physicians to work with lawmakers to repeal 1990s-era statute that loosened restrictions on opioid prescribing.

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But these suggestions demand even more of physicians who are already hard pressed for time. And as Jeffrey Fudin of the American Academy of Pain Management explained, “Inappropriate opioid prescribing is undertaken by a small percentage of prescribing physicians.” A more helpful response to rising opioid-related deaths, Fudin argues, is a collaborative care approach. Other health care professionals, including pharmacists, should participate in a pain patient’s treatment. And other measures, such as regular exercise
and avoiding alcohol, should accompany opioids in the treatment of patients’ pain.

Both Franklin and Fudin note the absence of evidence on opioids’ usefulness for treating noncancer pain long term, but they arrive at vastly different conclusions. Franklin interprets this absence as a form of evidence itself – concluding that opioids are not useful for long-term pain patients. Fudin, on the other hand, interprets the lack of evidence as a need more research and leadership on the issue of pain management. He also notes that patients turn to opioids because no strong evidence shows effective ways to relieve pain with non-opioid treatment strategies.

As policymakers, care providers and patients continue to wrangle with how and when to use opioids for pain management, they must walk a fine line. Blanket attacks on pain medication constitute, in Fudin’s words, “an atrocity for legitimate opioid-requiring patients with persistent pain syndromes.” But unless policymakers combat prescription drug abuse with precision, legitimate patients could wind up losing the only effective treatment option they have.

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