We all know pearls in medicine. Some withstand the test of time—presumably due to evidence, others not so much.
A story in the WSJ caught my eye big time because the central subject, Russel Portenoy, practices locally and has a national reputation in pain management. More importantly, the piece challenges weighty dogma.
I should add the report does not portray Dr. Portenoy in favorable light. The journalist cites multiple interviews in which he contradicts foundational positions he has disseminated over time. These tenets have significance if you practice hospital medicine.
I always believed the “less than 1% rule,” and shame on me for never digging deeper:
Dr. Portenoy helped write a landmark 1996 consensus statement by two professional pain societies that said there was little risk of addiction or overdose among pain patients. In lectures he cited the statistic that less than 1% of opioid users became addicted.
Today, even proponents of opioid use say that figure was wrong. “It’s obviously crazy to think that only 1% of the population is at risk for opioid addiction,” said Lynn Webster, president-elect of the American Academy of Pain Medicine, one of the publishers of the 1996 statement. “It’s just not true.”
The figure came from a single-paragraph report in the New England Journal of Medicine in 1980 describing hospitalized patients briefly given opioids. Dr. Portenoy now says he shouldn’t have used the information in lectures because it wasn’t relevant for patients with chronic noncancer pain.
For such a widely used therapy, there is relatively little scientific evidence that opioid drugs are safe and effective for long-term use. “Data about the effectiveness of opioids does not exist,” Dr. Portenoy said in his recent Journal interview. To get a painkiller approved, companies must prove that it is better at reducing pain than a sugar pill during short trials often lasting less than 12 weeks.
More thought leaders are rejecting the notion narcotics are mainstream drugs for pain management. In fact, they equal trouble, and consequently, hospitalists must exercise caution when initiating therapy before discharge. Acute evolves to chronic use, and then the cycle begins—and one the community physician cannot break:
Perhaps a death rate of 1 per 1000 per year would be acceptable if high-dose opioid treatment was highly effective for relief of chronic pain as McCarberg and colleagues claim. Studies suggest that short-term treatment of chronic pain (up to 16 weeks) reduces pain scores approximately 30%.2There are no studies that document pain relief with long-term opioid treatment, which is the norm in clinical practice.
Unfortunately, with the limits of NSAID use due to patient age and comorbidity, we cannot practice securely. I don’t have an answer. However, when I see a table like the one below, along with the statistics of associated deaths and ER visits, I know we reached a tipping point. Firsthand in NY State (and many bills in other locales resemble ours), I see the impending stresses on our practice dynamism.
Narcotic dispensing due to oversight, I sense, will alter how the current generation of trainees view analgesic use. Lack of data and guidance does not help.
Remember, “we need a bigger boat“? Well, “we need some better drugs.”
UPDATE: FDA taking action:
Regulators will reopen debate over opioid painkillers next year as the U.S. government considers ways to reconcile the needs of patients suffering chronic ailments with the risks of addiction and recreational drug use.
The Food and Drug Administration plans a two-day public hearing starting Feb. 7 after receiving “comments, petitions, and informal inquiries concerning the extent to which opioid drugs should be used in the treatment of pain.” The meeting is intended to help understand how doctors define pain and measures used to limit opioid use, the agency said today in a statement.