Opioids should be last resort to treat chronic pain, says draft CDC guideline
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h6905 (Published 18 December 2015) Cite this as: BMJ 2015;351:h6905
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Are you telling us, it is not so and not common practice?
I imagined this was basic medical care.
Who is suppose to be supervising the standards of care?
How is one to trust anything in one's care any longer, if even the professional medical bodies such as the GMC in the UK or the provincial colleges in Canada, are unable to ensure the standards, to which adherence should be mandatory?
Is it because they have a huge conflict of interest with third parties? Has complacency set in?
These so-called champions of patient care are the ones destroying patient confidence in the healthcare system.
Competing interests: No competing interests
There are many remedies for treating chronic pain ranging from medications to invasive techniques, including injections and surgery. Often ignored and underused are the diverse non-pharmacologic therapies, such as psychotherapy, physical therapy, occupational therapy, Yoga and acupuncture. So far at present less than 40% of people with chronic pain use any non-pharmacological therapy – either in blend with medicines or on its own.1 Because of the inadequate education the majority of physicians receive on chronic pain in medical school and postgraduate guidance, they often have modest acquaintance with the potential role these therapies have in managing this problem and much less any skill in utilizing them.
A systematic review of randomized controlled trials established strong evidence that multidisciplinary treatments for chronic pain are better to usual medical treatments.2 The non-pharmacological Strategies included cognitive behavior therapy, physiotherapy, exercise, relaxation and patient education etc.2
If non-pharmacological treatment plan are not achieving the preferred results on their own, a non-opioid analgesic can be used as an add-on. Non-opioid analgesics should be trialed before opiates.2 Paracetamol is considered the first-line drug therapy and can be used as an adjunct to non-pharmacological or other pharmacological therapies as per the risk benefit balancing act. 3 Adjuvant analgesics including tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors and anticonvulsants can be considered before opioids.3
So immediately jumping to opioid use without taking care of other available modalities is not reasonable except in case of cancer pain/terminal pain.4
References:
1. Henderson JV, Harrison CM, Britt HC, et al. Prevalence, causes, severity, impact, and management of chronic pain in Australian general practice patients. Pain Med 2013;14:1346-61.
2. Scascighini L, Toma V, Dober-Spielmann S, et al. Multidisciplinary treatment for chronic pain: a systematic review of interventions and outcomes. Rheumatology (Oxford) 2008;47:670-8.
3. (Faculty of Pain Medicine, Australian and New Zealand College of Anaesthetists. Principles regarding the use of opioid analgesics in patients with chronic non-cancer pain. 2010. [Full text] (accessed 19 December 2015)
4. Dowel D, Haegerich TM, Chou R, US Centers for Disease Control and Prevention. CDC guideline for prescribing opioids for chronic pain: United States, 2016. Dec 2015. www.regulations.gov/contentStreamer?documentId=CDC-2015-0112-0002&
disposition =attachment &contentType=pdf.
Dr. Harminder Singh
Associate Professor pharmacology
Baba Farid University of Health Sciences, PUNJAB, INDIA
dr_harminderchahal@rediffmail.com
Competing interests: No competing interests
Re: Opioids should be last resort to treat chronic pain, says draft CDC guideline
Chronic pain management with opioids is laden with side effects such as abuse, dependence, narcolepsy, etc. The harm of using opioids in the long run, outweigh the benefits of reducing pain. Instances of overdose leading to death is another factor to consider. Under such circumstances, we need to look for alternatives to opioids.
There are remedies in complementary medicine such as Homeopathy, Ayurveda, Unani, acupressure, acupuncture, yoga, naturopathy, etc. which are effective in chronic pain management. For management of chronic pain syndrome, use of hyperbaric oxygen therapy has also been in vogue in specialised centres with this facility. There are other modalities such as behavioural therapy using hypnotherapy that can also be effective. However, there are variations between individuals in the response to these modalities where one system may be effective for one person while another person may respond to another modality of therapy. Thus, individualised therapy needs to be looked at for pain management. We also favour the view held by the CDC guidelines.
Competing interests: No competing interests