The medical community has learned the hard way with opioids that randomized controlled trials lasting only a few months aren’t enough to predict health consequences of long-term use.
A position paper by the American Academy of Neurology (AAN), published Sept. 30, states that the risk of dependence with long-term use, combined with the poor understanding of best practices, makes the overall risk of opioid use vastly outweigh the potential benefit for many patients.
Study author, Dr. Gary Franklin, a research professor of environmental and occupational health sciences at the University of Washington, said according to his knowledge, this is the first time a major professional medical society has published such a stance.
Most pain specialists find that some of their patients benefit from opioids, but more studies are needed to understand exactly who these patients are. There’s a good chance further studies will change the type of patients who are prescribed opioids, projects the AAN paper.
“It seems likely that, in the long run, the use of opioids chronically for most routine conditions, such as chronic low back pain, chronic headaches, or fibromyalgia, will not prove to be worth the risk,” the position paper states.
For the conditions that can benefit from opioids, prescribing physicians need better guidance on how to screen, dose, and monitor patients to prevent misuse.
According to the paper, most of the randomized controlled trials on opioids were shorter than four weeks, and not a single one was longer than a few months.
The opioid epidemic is “one of the worst man-made epidemics in history, … made by elements of organized medicine,” including leaders in the fields of pain management and drug companies and their surrogates, Franklin said.
The epidemic started with policy changes in the late 1990s, when states, without evidence of safety or effectiveness, began changing laws that had banned long-term use of opioids.
Franklin said in an email that three major misconceptions and mistakes contributed to this direction: The belief that opioids could be used safely and effectively in persons with chronic, non-cancer pain without fear of serious risk of addiction or serious adverse events; the establishment of laws that put no ceiling on opioid dose; and the misconception that the way to treat patients who developed a tolerance to opioids was to continue to increase dosage.
Opioid sales have increased by 300 percent since 1999, a rise that has tragically paralleled an increase in the number of overdose-related deaths, according to the Centers for Disease Control and Prevention (CDC).
Over 100,000 Americans have died from opioid-related causes since 1999, and the drugs have killed more people between 34 and 54 years of age than both firearms and car accidents, according to the AAN paper.
Franklin was careful to specify that using opioids for cancer pain or end-of-life care is still a valid use and that there is evidence showing that opioids provide significant short-term pain relief.
Still missing, though, is any kind of substantial evidence that opioids are good for long-term pain relief or that they improve patients’ ability to function long-term without a serious risk of overdose, dependence, or addiction.
The biggest lesson to learn from this, he said, is that rigorous safety trials are an absolute must before new medical treatments are given to the masses.
“Sometimes our own clinical leaders don’t know what they are talking about and say things based on their experience but not on sufficient scientific evidence.
“For drugs particularly, there should be proof of safety and efficacy before hoisting a potentially dangerous treatment on an entire population,” Franklin said.
Opioids are a class of painkilling drugs derived from the opium poppy (or a synthetic form of it). They include morphine and commonly known brand names like OxyContin, Percocet, and Vicodin.
The CDC has a prescription drug-monitoring database in 36 states that is supposed to track prescription information and help prevent abuse. However, according to the AAN paper, these programs are underutilized.
The AAN paper calls for doctors and lawmakers to seriously rethink and improve opioid prescription practices and laws.