More Guidance on Safe Opioid Use

February 24, 2015

Articles in two different internal medicine journals last week discussed when and how to use opioids for rheumatologic pain, despite their hazards and limitations.

Miller M,. Barber CW, Leatherman S, et al. Prescription Opioid Duration of Action and the Risk of Unintentional Overdose Among Patients Receiving Opioid Therapy. JAMA Internal Medicine.  2015;doi:10.1001/jamainternmed.2014.8071 Online February 16, 2015.

Mitchell H. Katz, MD. Editor's Note: Mitigating the Dangers of Opioids. JAMA Internal Medicine. 2015. doi:10.1001/jamainternmed.2014.8096. Online February 16, 2015.

March L. Review: In knee and hip OA, opioids reduce pain and improve function but increase adverse eventsAnnals of Internal Medicine. 2015;162(4):JC8. doi:10.7326/ACPJC-2015-162-4-008. 17 February 2015

There is no high-quality evidence that opioids are effective for chronic pain, and the risk of adverse effects, including death, is great.

But when patients are in pain, and nonopioid methods have proven ineffective, it can be difficult to send patients out of the office without an opioid prescription,” says the editor’s note to the study above, reported in JAMA Internal Medicine. Therefore, it is important to mitigate the dangers.

If they must use opioids, the overwhelming majority of Veterans Administration doctors start with short-acting opioids, the study found. They do use them for a significant number of osteoarthritis patients, and a few rheumatoid arthritis patients.

Miller did a retrospective study of 840,606 veterans in the Veterans Administration Healthcare System over ten years; 801,729 (97.7%) were using short-acting opioids and 18,887 (2.3%) were using long-acting opioids. There were 319 unintentional overdose events.

Major indications were back and neck pain (38%), osteoarthritis (21%), and rheumatoid arthritis (1.4%).

Short-acting opioids were safer than long-acting opioids. The risk of overdose was more than twice as high among patients starting long-acting than short-acting opioids.

The risk of overdose was also more than five times as high for long-acting opioids in the first two weeks after starting them.

The authors recommend using short-acting agents whenever possible, especially during the first two weeks of treatment. The editorial also warns against high doses.

The third article above, by March, is a commentary on the 2014 Cochrane review of opioids for hip or knee osteoarthritis. Cochrane concluded that there was a small mean benefit of non-tramadol opioids, but significant increases in the risk of adverse events.

The pain outcome did not meet a minimal clinically important difference, and opioids are recommended only as a last resort.

March notes that, in the Cochrane review, the median duration of trials assessing pain was only four weeks. The Cochrane review didn't go into exercise and weight loss.