An Alarming Development

Long-Term Opioid Use in Non-Cancer Pain by PD Dr. med. Winfried Häuser, Dr. med. Fritjof Bock, Dr. med. Peter Engeser, Prof. Dr. med. Dr. rer. nat. Thomas Tölle, Dipl.-Psych. Anne Willweber-Strumpf, Prof. Dr. med. Frank Petzke in issue 43/2014

The “Long-Term Opioid Use in Non-Cancer Pain“ guideline (1) was revised to provide a rational framework for the controversially discussed use of opioid analgesic drugs in the treatment of non-cancer pain. One of the key messages of the updated guideline is that approximately 25 percent of patients with osteoarthritis, diabetic polyneuropathy, post-herpetic neuralgia, and chronic low back pain benefit from long-term opioid treatment.

The number of opioid drug prescriptions has, as is generally known, significantly increased. Given the high prevalence and vague definition of chronic back pain, this development is alarming. In the United Stated, the number of deaths caused by opioid analgesic drugs has meanwhile surpassed those for heroin and cocaine significantly (2).

One third of the patients receiving long-term opioid treatment for non-cancer pain will develop an opioid use disorder (3). Both these findings relate to the fact that there is a gap between real-world patient care and the world of scientific studies and that these drugs are used in a too broad and uncritical manner. Opioid analgesics do not only carry risks for the patients who have been prescribed these drugs; they also link the legal world of medicine with the illegal world of street drugs, as they move from older patients who receive the prescriptions to younger drug addicts (secret “diversion” in the family, sale on the black market, “recycling” of spent opioid patches). It is imperative to filter out those patients in whom opioid analgesics are contraindicated (e.g. because of previous addictions of any kind, including smoking) or who require precautionary measures.

During “participative decision-making“ (1), the physician must seek the agreement of the patient to discontinue the medication if the treatment targets are not met—and the physician has to execute on this, if necessary (4). Here, taking a thorough medical history is crucial which covers previous treatment experiences, personality and mental health comorbidities (especially addictions). The key recommendations fall short of adequately addressing these aspects.

Should all of this be ignored, we may face a development similar to that in the United States—and in gerontopsychiatry we will be confronted with the cumulative final common path of this problem.

DOI: 10.3238/arztebl.2015.0251a

Dr. med. Dirk K. Wolter

Psykiatrien i Region Syddanmark

Gerontopsykiatrisk Afdeling Haderslev, Haderslev, Dänemark

Conflict of interest statement
The author declares that no conflict of interest exists.

References

1. Häuser W, Bock F, Engeser P, Tölle T, Willweber-Strumpf A, Petzke F: Clinical practice guideline: Long-term opioid use in non-cancer pain. Dtsch Arztebl Int 2014; 111: 732–40

2. Manchikanti L, Atluri S, Hansen H, et al.: Opioids in chronic noncancer pain: have we reached a boiling point yet? Pain Physician 2014; 17: E1–10

3. Juurlink DN, Dhalla IA: Dependence and addiction during chronic opioid therapy. J Med Toxicol 2012; 8: 393–9

4. Ballantyne JC, LaForge KS: Opioid dependence and addiction during opioid treatment of chronic pain. Pain 2007; 129: 235–55