Guidelines seek tighter opioid therapy control

Sustained opioid therapy should be prescribed only for chronic headache patients, according to stringent new guidelines that would exclude most headache patients.

A group revisited the outcomes of a five-year observational study of 160 patients on daily opioid therapy for intractable headaches and found that even fewer people benefited over time than had been reported in the original published manuscript. Instead of 26% cutting their pain by one-half or more as a result of opioid therapy, doctor said “no more than 15% of those patients did well.” He attributed the overestimate to “a significant disconnect between objective markers and patient perception.” Patients were less than honest about their analgesia use.

Even though the program was tightly controlled the investigators determined that noncompliance was high and that about half of the patients had continuing increases in their opioid doses. Further, a more recent study recycled that most patients on opioid therapy have behavioral disturbances. His colleagues reviewed 267 consecutively admitted patients, of whom 76% were discharged with moderated to significant pain control. Opioid use was highest in patients with borderline,  narcissistic, and antisocial personality disorders as defined under Axis II, Cluster B of the Diagnostic and Statistical Manual of Mental Disorders IV.

Headache patients who obtain opioids are different, unwilling or unable to stop taking opioids even if their headaches do not lessen with therapy. Some patients use the prescribed opioid as a medication for something other than pain, such as relief of anxiety. Opioids make borderline patients angrier and more combative.

In many cases, physicians prescribe opioids against their better judgement. I believe that the behavior of the patient more than the pain itself often drives the doctor to give them opioids — if nothing else, to simply quiet them down. In order to help physicians say “no” to such patients, headache patients would have to meet all four of these criteria to be eligible for opioid therapy:

1. Older than 50 years.

2. Convincing moderate to severe pain occurring daily or almost daily with recognizable impairment.

3. Visited the physician at least four times over 3 months to ensure familiarity before the first opioid prescription is written.

4. A history of being compliant and trustworthy in use of medication.

Also, patients must meet one or more of these criteria.

1. A history of failing to respond to multiple appropriate treatments.

2. Pregnancy threatened by headache.

3. Significant confounding disease or treatment that aggravates headache or limits treatment.

Moreover, chronic headache patients should be disqualified from receiving opioid therapy if they have a moderate to severe Axis I diagnosis; past or current addictive disease (with the exception of a “non-drinking rehabilitated alcoholic”); any Axis II, Cluster B personality disorder, or moderate to severe somatoform or histrionic features.

Finally, opioid-treated patients must be seen frequently to ensure they are not abusing their medication. “If you start them you had better be willing and able to monitor and stop them.”