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From Group Health Research Institute, Seattle, Washington; Maimonides Medical Center, Brooklyn, New York; and Oregon Health & Science University and Kaiser Permanente Center for Health Research, Portland, Oregon.
Grant Support: By the Group Health Foundation and by the National Institute of Drug Abuse (R01 DA022557) and National Institute of Aging (R01AG034181), National Institutes of Health.
Potential Conflicts of Interest: Dr. Von Korff: Grant (money to institution): NIDA, NIA, Group Health Foundation; Grants/grants pending (money to institution): Johnson & Johnson. Dr. Deyo: Consulting fee or honorarium: UpToDate; Other: Board of Directors, Foundation for Informed Medical Decision Making. Dr. Chou: Grant: American Pain Society; Consulting fee or honorarium: American Pain Foundation. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M11-0929.
Corresponding Author: Michael Von Korff, ScD, Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Von Korff: Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA 98101.
Dr. Kolodny: Department of Psychiatry, Maimonides Medical Center, 920 48th Street, Brooklyn, NY 11219.
Dr. Deyo: Department of Family Medicine, Department of Medicine, and Center for Research in Occupational and Environmental Toxicology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239-3098.
Dr. Chou: Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
Author Contributions: Conception and design: M. Von Korff.
Drafting of the article: M. Von Korff, A. Kolodny, R.A. Deyo, R. Chou.
Critical revision of the article for important intellectual content: M. Von Korff, R.A. Deyo, R. Chou.
Final approval of the article: M. Von Korff, R.A. Deyo, R. Chou.
Obtaining of funding: M. Von Korff.
In the past 20 years, primary care physicians have greatly increased prescribing of long-term opioid therapy. However, the rise in opioid prescribing has outpaced the evidence regarding this practice. Increased opioid availability has been accompanied by an epidemic of opioid abuse and overdose. The rate of opioid addiction among patients receiving long-term opioid therapy remains unclear, but research suggests that opioid misuse is not rare. Recent studies report increased risks for serious adverse events, including fractures, cardiovascular events, and bowel obstruction, although further research on medical risks is needed. New data indicate that opioid-related risks may increase with dose. From a societal perspective, higher-dose regimens account for the majority of opioids dispensed, so cautious dosing may reduce both diversion potential and patient risks for adverse effects. Limiting long-term opioid therapy to patients for whom it provides decisive benefits could also reduce risks. Given the warning signs and knowledge gaps, greater caution and selectivity are needed in prescribing long-term opioid therapy. Until stronger evidence becomes available, clinicians should err on the side of caution when considering this treatment.
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To the Editor: Von Korff et al's "Long-Term Opioid Therapy Reconsidered" (1) captured many of the challenges and concerns we share related to efficacy and safety of opioids. Of particular interest was the concept of "unplanned transitions to long-term use of opioids." In our experience, an entire office visit dedicated to the issue of pain, including a detailed assessment and plan informed by shared decision- making and sound principles of multi-modal care, is a judicious time investment that pays dividends in terms of patient and provider satisfaction and the rational prescription of opioid therapy. Realistic analgesic targets, the transparent discussion of risks, and full disclosure of practice policies may even lead to decreased utilization of urgent visit appointments and emergency department services. Such comprehensive pain assessment and management requires motivated and educated providers, yet currently only five of the nation's 133 medical schools have a mandatory course on pain, and just 17 offer such courses as an elective (2). Thus, we continue to advocate for increased attention in undergraduate and graduate medical education on outpatient management of chronic pain.
William C. Becker, MD Daniel G. Tobin, MD Yale University School of Medicine
References: (1) Von Korff, M; Kolodny, A; Deyo, RA; Chou R. Long-Term Opioid Therapy Reconsidered. Ann Intern Med. 2011; 155: 325-328. (2) Roehr, B. US needs new strategy to help 116 million patients in chronic pain. BMJ. 2011; 343:d4206.
Von Korff et al.(1) appropriately reported the challenge of assessing long-term opioid risks to legitimate patients as well as clinician controlled opioid access dangers for abuse (addiction and / or diversion) for patient and public safety.
However, the authors erroneously invoked the phrase "disabling chronic pain." Pain is an impairment and if the condition is treated such that pain is minimized, then pain is not disabling. The analogy is that of treatment of addiction impairment in that if the addiction is treated then addiction is not disabling.
Johns Hopkins clinicians mandated employment for opioid treatment of addiction to continue, reporting 93% of truly successfully treated addicts achieved employment, usually full time work.(2) The converse of successful treatment was declared by continued patient solicitation of opioid narcotics without objective evidence of benefit in terms of return to full time work.
Similarly, if the allegation of disability persists despite the risks of opioids amongst the spectrum of options available to treat chronic pain, then the attendant dangers inherent to the privilege of opioid access often needs to be rescinded, especially if dose is appreciable.
It has recently been reported that the benefits of opioids is marginal for most patients such that patients should be referred to pain specialists primarily for specialized nerve block procedural skills of the clinician.(3)
The proposal has merit as safer alternatives should be initiated before considering long term opioid therapy.(1) The average patient appreciates nerve block mediated potently lowered pain intensity by 40%(4) such that opioids are not even solicited. However, given that opioids may effect up to 30% antinociception,(3) the safe, legitimate opioid candidate may achieve a summed pain relief of 70%.
In addition, presumably secondary to opioid dosing minimization effects, it has been reported that the non-addictive option of injections, when added to proper patient monitoring, decreases controlled substance abuse nearly 50%, from 17.8% to 9%.(5)
As the authors appropriately and repeatedly indicated, patient and public safety are optimized by proper patient selection and judicious opioid prescribing.(1) If pain is truly sufficiently profound as to warrant opioids, patients will discard consumption of disability resources to embrace the goal of return to full time work. "Carefully selected" patients are appropriate for prudent, "cautious, and vigilant" long term opioid candidacy as objectively defined by demonstrating "increased function" of sufficiently "meaningful" and "decisive benefit"(1) of full time work to assume the risk and benefit of opioid medications.
Aaron S. Geller, M.D. GELLERTreatment@hotmail.com Assistant Professor, Tufts University School of Medicine, New England Medical Center, Boston Nashua Pain Management Corp, 154 Broad St., Nashua, NH 03063 603-233-6317 University of Pennsylvania School of Medicine, 1991 Board Certified, American Board of Pain Medicine, 1999 Board Certified, American Board of EMG/ Peripheral Neurology/ Electrodiagnostic Medicine, 1997 Board Certified, American Board of Physical Medicine & Rehabilitation branch of internal medicine, 1996
1. Von Korff M, Kolodny A, Deyo R, et al. Long-term opioid therapy reconsidered. Ann Intern Med. 2011 Sept;155(5):325-328.
2. Kidorf M, Neufeld K, Brooner RK. Combining stepped-care approaches with behavioral reinforcement to motivate employment in opioid- dependent outpatients. Subst Use Misuse. 2004;39(13-14):2215-2238.
3. Grady D, Berkowitz SA, Katz MH. Opioids for chronic pain. Arch Intern Med. 2011 Sept 12;171(16):1426-1427.
4. Bogduk N. Pharmacologic alternatives for the alleviation of back pain. Expert Opin. Pharmacother. 2004;5(10):2091-2098.
5. Manchikanti L, Manchukonda R, Damron KS, et al. Does adherence monitoring reduce controlled substance abuse in chronic pain patients? Pain Physician. 2006;9(1):57-60.
The opinion piece "Long term opioid therapy reconsidered" resonates with experiences at our public health care organization, Denver Health (DH). DH is an integrated delivery system that provides primary care to a primarily indigent population through eight federally qualified community health centers (CHC). The authors advocate safer prescribing practices including better patient selection and closer monitoring. We would add that there is a paucity of published data on long term opiate therapy (LOT) in safety net populations and even less literature on outcomes of LOT discontinuation. We have attempted to do this as part of a recent quality improvement project at Denver Health by reviewing the records of 121 patients who had been flagged as terminated from LOT by their primary care physician between Jan 1st 2008 and December 31st 2011. This work adds to the limited published information on LOT in safety net health care organizations.
In the past decade opioid fills for chronic pain have increased as a percent of total pharmacy fills at DH. As providers at DH have become more diligent about administering treatment agreements, performing regular urine drug screens, requiring regular clinic visits, and monitoring patients through Colorado's Prescription Drug Monitoring Program, they have identified many patients as inappropriate for LOT. At one of our CHCs, we tracked patients deemed no longer eligible for LOT (N=121) due to opioid misuse or behavior that violated their treatment agreement. Patients were terminated from LOT for the following, not mutually exclusive, reasons : lost prescriptions (2.5%), fraud--presenting false identification or selling pills (5.0%), abusive behavior to staff (6.6%), running out of meds early (19.0%), doctor shopping (21.5%), and urine drug screen violation on at least 2 occasions (65.3%, with the most common violations being cocaine, tetrahyrdocannabinol, benzodiazepines, alcohol, and methadone). Eighty- five percent of this cohort was on schedule II opioids at the time of termination, likely a reflection of better tracking and monitoring for schedule II vs. schedule III opioid therapy. The rate of discontinuation from schedule II opioid therapy during this time period was 14%. Based on chart review many patients discontinued DH primary care follow-up soon after the cessation of LOT (49%). Twenty-two percent of the cohort was re-started on opioid therapy 6 or more months after the initial termination, with variability in ongoing monitoring across clinics and providers. Sixty-eight percent of patients who were re-started on opioid therapy at the same CHC were again discontinued from opioid therapy, whereas only 18% of patients who were re-started at a different CHC were later identified, again, as inappropriate for LOT.
Key observations from this analysis are a high rate of opioid misuse or addictive behavior and a variable approach to patients on LOT across the organizaiton. We have identified a need for a systematic approach for LOT across providers and clinics both for patient selection and monitoring which should be facilitated by the development of a LOT registry.
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