Long term opioid pain therapy evidence limited, linked to serious harms

1. According to this systematic review, long-term opioid therapy for chronic pain was associated with increased risk of serious harms, such as overdose, abuse, and heart attacks.

2. Evidence suggesting that chronic opioid use improves quality of life or pain outcomes was sparse, and the authors did not identify any high quality studies of the effectiveness of long-term opioid therapy that met their inclusion criteria.

Evidence Rating Level: 2 (Good)           

Study Rundown: Chronic use of opioid-based pain relievers has increased substantially in the last two decades in the US. However, their overall outcomes are largely unknown, so this study reviewed previously published articles to analyze the benefits, harms, methodology, dosing and comparative effectiveness of long-term opioid use for chronic pain. Most of the studies described harms associated with chronic opioid use. In particular, opioid abuse and overdose, bone fractures, heart attacks, motor vehicle accidents and erectile dysfunction were associated with long-term use of opioid therapy. The risk of some of these harms, including abuse, overdose, and heart attacks, increased along with the opioid dose. This study was limited by the paucity of high-quality published literature on long-term opioid therapy. Specifically, the authors were unable to identify any studies on the effectiveness of this therapy that met their criteria for inclusion in this analysis, and were therefore unable to comment on this key question. Overall, this study highlights several key harms that may be linked to chronic opioid use, particularly as doses increase. But another significant result was the distinct lack of rigorous research to guide use of this ubiquitous class of pain medications.

Click to read the study, published today in the Annals of Internal Medicine

Relevant Reading: Opioids for Chronic Noncancer Pain: A Meta-Analysis of Effectiveness and Side Effects

In-Depth [systematic review]: This review is an update of a 2009 review for the American Pain Society and American Academy of Pain Medicine. It included 35 publications that evaluated chronic (>3 months), non-parenteral opioid use. Data on five characteristics were sought: long-term effectiveness, harms, opioid dosing strategies/comparative effectiveness of different opioids, abuse/misuse risk assessment instruments and risk mitigation strategies. No studies were identified that addressed effectiveness or risk mitigation. Included studies were highly heterogeneous in methodology, quality, and results, limiting summative conclusions and preventing a planned meta-analysis. However, this review found general dose-dependent associations between chronic opioid use and the harms, no clear differences between the effectiveness of various opioid medications, and poor evidence evaluating the utility of several risk assessment tools. This analysis highlights the urgent need for high-quality, randomized or observational studies to gauge the long-term effectiveness of various chronic opioid therapies and their associated harms to better develop the tools and strategies needed to mitigate these harms.

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