Author: Bob Kronemyer
Care plans that include opioids provide limited effectiveness in treating persistent pain, according to a project conducted at Dartmouth-Hitchcock Medical Center.
“Consequently, first-line drugs for the treatment of persistent pain should almost always be nonopioids,” said one of the project leaders, Debbie Fabry, BS, RN-BC, SANE, a nurse manager at the Center for Pain and Spine, which is a hospital-based clinic located within Dartmouth-Hitchcock Medical Center (DHMC) in Lebanon, N.H.
But if a provider is considering prescribing opioids for persistent pain, the standard of care should include prescribing guidelines by the CDC, which generally restrict prescribing to a three- to seven-day supply; appropriate standardized risk assessment tools; routine and random urine drug testing; and a prescription drug monitoring program, according to Ms. Fabry, who presented results at the 2019 annual conference of the American Society for Pain Management Nursing, in Portland, Ore. (abstract C1).
For the project, 166 adult patients with persistent pain representing 255 opioid prescriptions were selected to begin a downward titration to reduce or stop opioid treatment between February 2018 and February 2019. Morphine milligram equivalents (MMEs) ranged from 1 to nearly 375 mg per day. “Approximately 16% of patients were taking over 90 MMEs, thus exceeding the CDC guidelines for opioid prescribing,” Ms. Fabry said.
A full-time pain psychologist was subsequently hired.
“The key was thoughtfully and gradually tapering persistent pain patients off opioids,” Ms. Fabry said.
Opioid Status Quo
Alternative therapies included reconsideration of interventional procedures; novel nonopioid medications, such as low-dose naltrexone (LDN); mindfulness; and a 14-day functional restoration program entailing psychosocial interventions, therapeutic exercise and educational presentations.
Nonetheless, pain scores for the middle 50% of study patients remained statistically unchanged. “This suggests that either opioids were never benefiting the patients or that the alternatives they were offered provided equal relief, without the risks associated with opioids,” Ms. Fabry said.
As of May 1, 2019, nearly all patients (153/166) had successfully tapered off all opioid prescriptions. “This reduction in prescriptions translated to 14,475 fewer pills entering our community on a monthly basis,” Ms. Fabry said. “However, despite leading the way in this change, we found there were many providers in the community who were willing to maintain the status quo of opioid prescribing. Most surprising was that 8% of the patients in this project returned to their primary care provider for pain management.”
Outside the scope of this project were patients for whom evidence-based medicine supported continued treatment with opioids: acute trauma/postoperative, cancer-related pain, or patients who were receiving palliative care.
In 2016, according to a CDC report, the New Hampshire opioid overdose rate was 39 deaths per 100,000, the second highest rate in the country. “While the primary driver for this project was the apparent lack of efficacy of opioids, being a ‘hot zone’ in the national opioid crisis was certainly a significant secondary driver,” said Ms. Fabry, noting that the availability of opioids in the home poses a risk for diversion and/or accidental overdose.
Two future plans for the Center for Pain and Spine at DHMC are to expand research on LDN, which is now on the formulary at Vermont Medicaid; and when appropriate, transition patients on intrathecal pumps from opioids to ziconotide (Prialt, TerSera).
Interesting but Inconclusive
Jeremy Adler, DMSc, PA-C, a pain management PA at Pacific Pain Medicine Consultants in Encinitas, Calif., said the project is interesting but not quite adequate to draw conclusions about the general population of patients prescribed opioids.
“Opioids, like any therapy in medicine, have to balance essentially three variables,” Dr. Adler said. “Treatment has to be effective for the application, has to be tolerated, and it has to be safe. The project appears to concentrate principally on efficacy, with pain scores as the measurement of success or failure.”
For some patients, alternative therapies may provide similar efficacy to opioids, “but those therapies may or may not satisfy safety or tolerability factors,” Dr. Adler said.
Also, the CDC guideline described for the project “was developed for primary care, not a pain management specialty center,” Dr. Adler said. “Plus, illicit fentanyl is a cause of many overdose deaths, and impacting this through prescribing practices is undetermined.”
Despite these reservations, Dr. Adler noted the project highlights the need to better understand which patients would most likely benefit from opioid therapy and those who would not. “Certainly, not all patients prescribed opioids are benefiting from them, and finding safer, effective and tolerable treatments is a priority,” he said. “As with any medical therapy, we have an obligation to understand a particular therapy and not simply blanket-provide it to all patients in all settings.”