Authors: Franklin GM., Neurology 2014 Sep 30; 83:1277
Applying an American Academy of Neurology position paper to clinical practice
In this position paper, the American Academy of Neurology reviews the rise in opioid-associated harms, the lack of evidence for long-term effectiveness, and the policy response to rising abuse and overdose. The paper includes proposals for best practices for safe opioid prescribing, including tracking pain and function; documenting all opioid sources; conducting random urine testing; screening for histories of substance abuse and depression, anxiety, or posttraumatic stress disorder; using a “patient treatment agreement”; and prescribing doses above about 120 morphine-equivalent mg/day only when the patient has “sustained meaningful” improvements in pain and function, in consultation with a pain management specialist.
Comment
The goal of a position statement should be to diminish harms while not worsening undertreatment or stigma. In this light, several limitations of this position statement are worth noting:
· Although there is now broad acceptance of a universal-precautions approach, including careful patient selection, ongoing adherence monitoring commensurate with risk, careful reassessment when doses increase, and caution in coprescribing other centrally acting drugs, some recommended practices are not considered routine.
· “Treatment agreements” are not universally preferred,pain specialist consultation is neither generally feasible nor likely to provide clarity, functional assessment must consider the potential for improvement, and the suggestion to discharge patients after opioid misuse (a secondary recommendation) does not reflect the reality of primary care.
· The term “chronic noncancer pain” has no agreed-upon clinical meaning and ignores the variation that characterizes chronic pain; generalizations applied to this ill-defined group need careful review.
Evidence of long-term effectiveness is insufficient in all populations, including cancer, but this not the same as evidence of no long-term benefit and should not be used to justify the conclusion that harms generally outweigh benefits in any population.
Clinicians must recognize the potential for serious harms and must carefully weigh risk and benefit when selecting and treating patients with chronic pain using opioids.