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Pain med prescribing guidelines mostly agree

By Kathryn Doyle

NEW YORK (Reuters Health) - Doctors are well aware that prescribing powerful painkillers known as opioids carries risks for addiction, misuse and accidental overdose - but at least professional guidelines agree on the precautions they can take, say researchers.

Opium-related drugs, like Oxycontin, Percocet, Percodan and methadone can be very addictive and are usually prescribed for just a week or two for intense short-term pain, though their use for longer-lasting pain is growing.

Sales of opiates in the U.S. increased by 300 percent since 1999, according to the Centers for Disease Control and Prevention. Three out of four deaths due to prescription drug overdose involve opioids. And for every death there are ten admissions to treatment centers for addiction.

The rapid rise in opioid use over the last ten years left little time to research best practices for giving out long-term prescriptions to treat chronic pain, according to Dr. Teryl Nuckols at the David Geffen School of Medicine at the University of California, Los Angeles.

Many organizations offer guidelines for doctors, but it wasn't clear if they agreed or differed greatly, he told Reuters Health. So he and colleagues set out to review the guidelines published since 2006.

Surprisingly, the team found that most of them agreed on key points.

"There is widespread agreement about some basic ways of mitigating the risks associated with prescribing opioids for chronic pain," Nuckols said.

"Guidelines often differ substantially, even when there is pretty good literature addressing the clinical questions," he said. As an example, he pointed to the question of giving screening mammograms to women ages 40 to 50, where there is much evidence but little agreement.

In their review, Nuckols' group assessed recommendations for doctors that drew on evidence for prescribing the powerful drugs to patients with non-cancer pain that lasts more than three months.

According to one study, 18 percent of people with this type of chronic pain use opioids.

Most guidelines recommended that clinicians avoid doses greater than 90 to 200 milligrams of "morphine equivalents" daily and that they have additional knowledge to prescribe methadone. Doctors should also increase dosages slowly and monitor for side effects when first prescribing the drugs, and reduce doses by at least 25 percent to 50 percent when switching opioids.

Guidelines agreed, as well, that opioid risk assessment tools, written treatment agreements and urine drug testing can help to manage risks of overdose and misuse Nuckols' team writes in the Annals of Internal Medicine.

More research is needed to determine the quality of these guidelines, the researchers note. And whether they're being followed by doctors is still another question.

"Unfortunately, guidelines are not followed as often as they should be," Nuckols said.

Doctors also make decisions based on online literature, lectures, journal articles, advice from other physicians and personal experience, he said.

Many of the recommendations pointed out in the review are not routinely used in many, if not most, clinical practices where opioids for chronic pain are prescribed, said Dr. Mel Pohl, medical director of the Las Vegas Recovery Center. He was not involved in the review.

Understanding dosing limits, knowing who is at risk of misusing, abusing or becoming addicted to prescribed opioids and what constitutes addiction versus the normal tolerance and dependence are important but nuanced aspects of prescribing these drugs, Martin D. Cheatle said.

Cheatle is director of the Pain and Chemical Dependency Program at the Center for Studies of Addiction at Perelman School of Medicine at the University of Pennsylvania in Philadelphia and also not involved in the review.

"Most medical school curriculums are notably lacking courses on pain and addiction," he told Reuters Health. "Since most of pain care is delivered by primary care physicians, who typically have the least amount of training, time and resources to manage these complex cases it is imperative that we disseminate critical and well vetted guidelines for safe opioid prescribing."

Educating doctors, especially primary care doctors, is the most important step, Cheatle said.

SOURCE: http://bit.ly/HRUZ8l Annals of Internal Medicine, online November 12, 2013.

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