Tuesday, October 14, 2014

Palliative Care Review of NIH's Opioid Webinar "Pathways To Prevention"

(Please welcome Sydney Dy, a palliative care physician who took great notes for a recent NIH web conference on opioid management. She shared those notes with her team, and in a great example of sharing medical knowledge more freely adapted them for Pallimed. -Ed.)

Years ago, when the local home hospice we worked with at the time supported physician home visits, I did an urgent visit on a Saturday night for a dying patient in a lot of pain with no medications in the home. I remember thinking how helpful the nice-looking young-adult grandchildren were with asking questions about what the concentrated morphine was that I obtained for them and how to use it. Unfortunately, I was unpleasantly surprised the next day to get a call that the patient needed another prescription for morphine... because those nice-looking, helpful grandchildren had used the first prescription for their own purposes that Saturday night.

Now that I've worked in palliative care in a cancer center for many years, I've become more and more aware of patients on chronic opioids - either on these medications for back pain or other issues before they come to us with their cancer, or patients who end up on them chronically after their cancer is treated - who clearly seem to be having more problems from the opioids than being helped by them - and often end up taking them in other ways than prescribed. Personally, I have learned to be far more cautious with opioid use and set expectations that we're going to get patients off of them when we are using them as short-term solutions, and we spend a lot of time getting patients off of opioids or dealing with opioid issues in our clinic. Clearly, opioids are an incredibly important tool for pain in palliative care - but they also have tremendous risks and burdens for our patients that we need to continually consider in our prescribing, and we need to be able to deal with these issues as palliative care clinicians, especially in the outpatient setting.

I was therefore very interested in the recent conference on Sept 29-30, "Pathways to Prevention - The Role of Opioids in the Treatment of Chronic Pain", which included a systematic review of the literature on this topic and presenters by many experts in the field, including Russ Portenoy.
The program book is at 
And the archived webcast is at

I would encourage anyone who prescribes opioids to listen to at least a little of this conference - in particular, I thought these presentations were very relevant to our specialty:

Jane Ballantyne
Russell Portenoy
Edward Covington
Nathaniel Katz
Steven D. Passik, Ph.D.

Here is a brief summary and some key points that I took away.

There is very little new helpful high-quality evidence that has been generated over the past decade on this issue, and many of the important issues will not be addressed in clinical trials. For areas where there is some evidence (e.g., risk of addiction with long-term opioid use), evidence is conflicting and studies are often short-term; long-term evidence is unlikely. Regardless, evidence is accumulating on the long-term risks and safety issues with opioids, both for patients and for those that end up getting the opioids from patients for whom opioids were legitimately prescribed; and many patients clearly do not seem to be benefiting from long-term opioids but end up being maintained on them because of the difficulty of getting them off and lack of available alternatives in most places in the US. In addition, most patients do not get adequate risk assessment and monitoring while on long-term opioids - these resources are rarely available and it is very time-consuming - and risk assessment before starting opioids is not very reliable. 

Chronic opioid use - 

There is a fine line (or perhaps a continuum, and significant overlap) between dependence, tolerance and addiction - (Jane Ballantyne gave a great discussion of this)
Very cautious about any chronic opioid use & lots of expert opinion (if not data, although we may never have this data) that it doesn't work for the majority of patients ... that we are often escalating opioids without necessarily giving patients value, other than having them feel that we are doing something. Clearly there are some patients who do very well and are helped by long-term opioids, but the challenge is that there are many patients who aren't and it is difficult to predict who will - and for patients who don't benefit, it's very challenging to discontinue.
If we do use them  - this requires very close monitoring, use mainly of long-term opioids. We should not expect anyone to manage a prescription of hundreds of pills. I am always reminded that most abuse happens with short-term opioids and that it is much easier to get into difficulty with them, and much more difficult for us to control as providers.

Safety with opioids - 

Be very cautious with co-prescribing with benzodiazepines! Major cause of death/ comorbidity. (This is a major issue in our cancer population where patients are often given these medications)

- It's easy for patients to take too much opioid - easy to forget that they had just taken a dose or just to take some extra medication when they are not feeling well.
Opioid risk assessment should be done before starting for any prolonged period of time, for everyone - note that this is challenging and often does not work, and so risk assessment should be continued.
Naloxone is becoming available more widely as an option to give to patients receiving opioids for pain -  there was positive discussion about this option and that its availability raises the importance of discuss opioid safety more with patients as well

Coming off of opioids - 

Need for research on tapering off - there is very little on how best to do this and what is helpful.
Patients will often have issues of fatigue, depressed emotional state for a prolonged time after coming off opioids
Many patients with substance abuse (and many on long-term opioids) have high pain scores

Other key issues - 
Headaches, low back pain, fibromyalgia should not be treated chronically with opioids (a new position statement from the American Academy of Neurology states the risks outweighs the benefits - http://www.neurology.org/content/83/14/1277.full)
Intermediate-term opioid use (intended for a few weeks or months) should be carefully managed as well - it is easy for this to turn into long-term opioid use without careful monitoring.
There's not as much of a difference between cancer pain and non-cancer pain as those of us who work solely in cancer would like to believe. Also - what is defined as "cancer pain"? In many studies - survivors and patients with chronic cancer issues are included along with patients with advanced disease - (Russ Portenoy)
 If we're prescribing opioids, at all - or recommending their use, or teaching about them - we need, as palliative care physicians, to be aware of these issues and have some education in chronic pain and addiction medicine.

If anyone else listened/ does listen to part of this conference, or has read some of the articles and guidelines on these issues, or has thoughts from your practice - appreciate hearing about them, especially if you have different opinions! 

Sydney Morss Dy, MD, MSc is Physician Leader, Harry J. Duffey Pain and Palliative Care Program, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, where she has had the great good fortune to work closely for many years with clinical pharmacists, pain specialists, social workers, and a psychiatric liaison nurse, who have taught her much about pain management and the use of opioids.

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