Dr Neha Pathak interviews Dr Daniel Clauw about how opioids fit into the treatment armamentarium when managing chronic pain.
What people failed to note in both of those studies is that the group of people that received the opioids didn't just not do better than the non-opioid people, they did worse. In both of those trials, when people got to a year out, the opioid-treated patients had statistically worse pain scores than the non–opioid-treated patients; these were two long, prospective trials where people were randomized to either opioid or non-opioid therapy.
I have always worried that in any group of chronic pain patients, if you look at those on opioids, they always look worse in every way. People say that's been confounded by indication and that we put the people with worse pain on opioids. I don't think that's true. I think that opioids actually make pain worse for a subset of patients with chronic pain. Because of that, we really should be using these as a last line if people are refractory to everything else.
The other thing that I don't think people are aware of is how high the all-cause mortality is. When someone is on an opioid, it's 70% higher or double in every year. It's not because of overdose deaths, but it's due to higher rates of myocardial infarctions, motor traffic accidents, suicides, and many other things that people die of at very high rates when they're taking an opioid.
I'm sorry about the rant, but I really do think we should be putting opioids where they were 25 years ago: You use them only when nothing else has worked.I think that's really helpful, and I appreciate the synthesis of the information. I think that, for many of us, it's very confusing and there's a regulatory hurdle.
Thank you to Dr Clauw for joining us and being our pain consultant, really helping us think about managing chronic pain in the post-opioid world.
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