Use of chronic opioid therapy for chronic noncancer pain has increased substantially. The American Pain Society and the American Academy of Pain Medicine commissioned a systematic review of the evidence on chronic opioid therapy for chronic noncancer pain and convened a multidisciplinary expert panel to review the evidence and formulate recommendations. Although evidence is limited, the expert panel concluded that chronic opioid therapy can be an effective therapy for carefully selected and monitored patients with chronic noncancer pain. However, opioids are also associated with potentially serious harms, including opioid-related adverse effects and outcomes related to the abuse potential of opioids. The recommendations presented in this document provide guidance on patient selection and risk stratification; informed consent and opioid management plans; initiation and titration of chronic opioid therapy; use of methadone; monitoring of patients on chronic opioid therapy; dose escalations, high-dose opioid therapy, opioid rotation, and indications for discontinuation of therapy; prevention and management of opioid-related adverse effects; driving and work safety; identifying a medical home and when to obtain consultation; management of breakthrough pain; chronic opioid therapy in pregnancy; and opioid-related polices.PerspectiveSafe and effective chronic opioid therapy for chronic noncancer pain requires clinical skills and knowledge in both the principles of opioid prescribing and on the assessment and management of risks associated with opioid abuse, addiction, and diversion. Although evidence is limited in many areas related to use of opioids for chronic noncancer pain, this guideline provides recommendations developed by a multidisciplinary expert panel after a systematic review of the evidence.
The damage done by the war on opioids: the pendulum has swung too far Timothy J Atkinson,1 Michael E Schatman,2 Jeffrey Fudin1,3–51PGY2 Pain and Palliative Care Pharmacy Residency, Stratton VA Medical Center, Albany, NY, 2Foundation for Ethics in Pain Care, Bellevue, WA, 3School of Pharmacy, University of Connecticut, Storrs, CT, 4Western New England University College of Pharmacy, Springfield, MA, 5Buffalo College of Pharmacy, State University of New York, Buffalo, NY, USAIn the United States, patterns of opioid use for the management of pain have drastically changed over the past 30 years. In the 1980s, the American pain medicine landscape was characterized by opiophobia, the fear to prescribe opioids. Around the turn of the millennium, however, we witnessed a fairly rapid shift to opiophilia, or the "overprescribing" of opioids. The ubiquitous undertreatment of pain was the catalyst for clinicians and pain societies to successfully lobby for increased use of opioids for all pain types, including non-cancer pain. The approval of new standards for pain management incorporating pain as the "fifth vital sign" by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)1 seemingly fueled this increase in opioid prescription. From 1991–2009, prescriptions for opioid analgesics tripled, with emergency department visits related to non-medical use of prescription opioid overdoses doubling from 2005–2009.2 In 2010, accidental overdose deaths associated with opioids increased for the eleventh consecutive year, highlighting the drastic shift in opioid use.3 The figurative pendulum began to swing toward opiophobia following the publication of data that demonstrated that the risk of addiction associated with chronic opioid use was likely underestimated.4 Guidelines for the use of controlled substances released by the Federation of State Medical Boards of the US in 1998 reflected this change in attitude.5 At present, there is a general consensus that opioids are over-prescribed and education among health care providers is sorely lacking, with considerable debate on how to appropriately address the issue not yet resulting in a balance between treating legitimate pain patients, and mitigating abuse, overdoses, and related deaths. In this environment, physicians and non-physician prescribers, health systems, regulatory agencies, and insurers are seeking tangible targets for intervention.
On February 6, 2005, the New York Times reported that Paul Kornak pled guilty to fraud and criminally negligent homicide a month earlier.1 Kornak was a nonphysician employee at the Stratton Veterans Affairs Medical Center (SVAMC) in Albany, New York. On November 21, 2005, a federal judge sentenced Kornak to the maximum prison term of six years. According to a local report, “At least one veteran died and 64 others suffered unduly or were harmed by the forgeries, which involved manipulating their medical backgrounds so they would qualify to participate in lucrative drug studies ….”2 A decade earlier, two pharmacists had warned that patients were placed at risk or had died because of similar unethical experimentation.2 Currently, an elusive federal investigation purportedly continues to determine which Department of Veterans Affairs (VA) physicians and administrators were an integral part of the patient abuse conspiracy, the cover-ups, and the retaliation against the two pharmacists who dared to expose the truth for greater than a decade; I am one of those pharmacists. I will share some personal experiences and lessons learned and review the professional guidelines and moral responsibilities that are explicit in the pharmacists’ code of ethics. I will also share the strategies that enabled me to persevere, should pharmacy colleagues face similar challenges to their professionalism and integrity.
The ongoing media maelstrom regarding opioids and classification of an "opioid crisis" during the initial decade of this millennium has stirred awareness, outrage and action among regulatory and other government agencies, professional clinician organizations, community pharmacy policies, legislators, patient advocacy groups, anti-opioid advocate groups, and others.However, mass media reports often skew or misdirect the aggregate facts in a possible effort to abridge or sensationalize stories. 1 Discernable distinctions, for example, are rarely drawn between licit pharmaceutical fentanyl, illicit fentanyl analogues, and certain highly potent analogues approved only for ungulates.The omission of this information has resulted in distorted public information that has far reaching consequences in medicine and policy development, as it leads to misunderstanding and misinterpretation of the facts by politicians, lay people and many clinicians. 2 It is particularly relevant today, as pharmaceutical fentanyl is often an essential drug for intubation regularly required for ventilation procedures in declining patients that may succumb to novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2).These distinctions are critical in the shifting landscape of the opioid crisis as prescriptions for opioids decrease yet overdose deaths remain alarmingly prevalent and continue to rise.Licit fentanyl was first synthesized in the 1950s via manipulation of another phenylpiperidine, meperidine, in an effort to develop a novel analgesic agent and laying the groundwork for pharmaceutical fentanyl and multiple analogues.Only a small percentage of those analogues are actually approved for medical use. 2 The remainder are dangerously potent with high binding affinity to opioid receptors and rapid entry to the CNS.These characteristics make them particularly hazardous when added to other illicit substances such as heroin, unbeknownst to the end-user with potentially deadly consequences. 3llicit fentanyl has had a dramatically increasing impact on opioid overdose deaths in the US over the past decade.According to provisional data from the 2018 Centers for Disease Control and Prevention, over half of the opioid-related overdose deaths in 2018 involved non-methadone synthetic opioids; the most common of which was illicitly manufactured fentanyl. 4Perhaps more telling are the annual data released by the New Hampshire Department of Justice, with the most recent of which indicating that less than 7% of 2019 opioid overdose deaths in the state were due to prescription opioids. 5These illicit opioids have affected the landscape of opioid abuse to the extent that the Drug Enforcement Agency (DEA) chose to emergently schedule all fentanyl-related substances (FRS) to schedule I as of February 2018.
Can we not work together to help family practitioners become more effective pain managers? Jeffrey Fudin,1,2,3 Timothy J Atkinson,4 Mena Raouf,4 Michael E Schatman5 1Stratton VA Medical Center, Albany, NY, USA; 2Albany College of Pharmacy and Health Sciences, Albany, NY, USA; 3Scientific and Clinical Affairs, Remitigate LLC, Delmar, NY, USA; 4VA Tennessee Valley Healthcare System, Murfreesboro, Nashville, TN, USA; 5US Pain Foundation, Bellevue, WA, USASnyder et al recently published a review in American Family Physician titled, “Treating Painful Diabetic Peripheral Neuropathy: An Update”, which provided an overview of pharmacologic treatment options for providers; however, some of the recommendations made by the authors were concerning.1 Recommendations that caught our attention included statements around pregabalin adjustment for renal impairment, using selective serotonin reuptake inhibitors (SSRIs) in the treatment of diabetic peripheral neuropathy (DPN), classification of tramadol, tapentadol, and oxycodone in DPN.
