Medicine & Research

In April 2016, the Centers for Disease Control and Prevention published updated guidelines in the Journal of the American Medical Association regarding the use of opioid medications. These guidelines provide recommendations based on best available evidence, interpreted and informed by opinion. The goal of these guidelines is to provide recommendations to primary care clinicians regarding how to prescribe opioid medications to patients suffering from chronic pain. Please note that these guidelines do not apply to treatment of active cancer pain, palliative care, or end-of-life care.
 
While these guidelines are not specific to all types of MS-related pain, they are applicable for many MS patients. According to Dr. Ben W. Thrower, director of the MS Institute at the Shepherd Center in Atlanta, “It is common for patients with multiple sclerosis to suffer from chronic pain conditions that require treatment with opioid medications.” Dr. Thrower went on to explain that these chronic pain conditions may or may not be related to MS.
 
There are 12 recommendations in the 2016 guidelines. The guidelines were assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. This type of grading method is commonly used when organizations publish guidelines.
 
Recommendation Categories: define to whom the guideline applies (i.e., all patients or individual patients):

•           Category A – applies to all patients
•          Category B – individual decision-making is needed

Evidence Types: define the strength of evidence used to make the recommendation.

•          There are 4 levels of evidence
•           Type 1 evidence is the strongest evidence; type 4 evidence is the weakest evidence.
 
• Recommendation 1: Nonpharmacological therapy and nonopioid pharmacologic therapy are generally preferred for chronic pain. If opioids are used, they should be combined with nonpharmacologic therapy and nonopioid pharmacological therapy, as appropriate. (Recommendation category, A; evidence type, 3)

• Recommendation 2: Before starting opioid medications for chronic pain, healthcare providers should establish treatment goals, including realistic goals for pain and function, and determine when or if the opioid medications will be discontinued if the risks outweigh the benefits. Opioid medications should only be continued when benefits outweigh risks. (Recommendation category, A; evidence type, 4)

• Recommendation 3: Before starting opioid medications and periodically during therapy, clinicians should discuss known risks and realistic benefits of opioid therapy. (Recommendation category, A; evidence type, 3)

• Recommendation 4: When initiating treatment with opioid medications, healthcare providers should prescribe immediate-release opioids instead of extended-release opioids. (Recommendation category, A; evidence type, 4)

• Recommendation 5: When initiating treatment with opioid medications, healthcare providers should prescribe the lowest effective dose. (Recommendation category, A; evidence type, 3)

• Recommendation 6: When opioids are used to treat acute pain, healthcare providers should prescribe the lowest possible dose of immediate-release opioids. No greater quantity than needed for the expected duration of therapy should be prescribed. Three days or less will be often be sufficient; seven or more days should rarely be needed. (Recommendation category, A; evidence type, 4)

• Recommendation 7: Healthcare providers should evaluate benefits and risks of therapy within one to four weeks of starting therapy with opioids. The benefits and risks should be re-evaluated every three months. If risks outweigh the benefits, the healthcare provider should taper the opioid medication or discontinue the medication. (Recommendation category, A; evidence type, 4)

• Recommendation 8: Prior to starting the opioid medication and periodically
during treatment, healthcare providers should evaluate risk factors for opioid-related harms. (Recommendation category, A; evidence type, 4)

• Recommendation 9: Prior to starting the opioid medication, healthcare providers should review the patient’s history of controlled substance medications use. (Recommendation category, A; evidence type, 4)

• Recommendation 10: When prescribing opioid medications for chronic pain, healthcare providers should use urine drug testing before starting opioid therapy and consider urine drug testing at least annually. (Recommendation category, B; evidence type, 4)

• Recommendation 11: Healthcare providers should avoid prescribing opioid medications with benzodiazepine medications. (Recommendation category, A; evidence type, 3)

• Recommendation 12: Healthcare providers should offer or arrange evidence-based treatment for patients with an opioid use disorder. (Recommendation category, A; evidence type, 2)
 
Several themes emerged in the 2016 guidelines. These themes are applicable to both patients having and not having multiple sclerosis. First, opioid medications should not be considered first-line treatments for pain. Nonpharmacological treatments (e.g., physical therapy or exercise) and nonopioid medications (e.g., nonsteroidal anti-inflammatory medications) should always be used first.
 
Second, when opioid medications are used, the lowest effective dose for the shortest duration of time should be prescribed. In these circumstances, immediate-release opioids are preferred to the controlled-release products.
 
Third, patients should be made continually aware of the risks and benefits of opioid medications. Risks include side effects. (One of the most common side effects associated with opioid medications is constipation. Patients should be made aware of this side effect so that they can request treatment for constipation if it occurs.) When risk outweighs benefits, patients should be tapered off the opioid medication.
 
Fourth, several of the recommendations address misuse of controlled substances, including opioid medications. The misuse of controlled substances is a serious problem in the U.S. Unfortunately, people who misuse opioid medications make it harder for the people who need the medications to receive them.
 
These guidelines suggested several practices for healthcare providers to implement so that opioid medications are not misused. By reviewing the controlled substance use history, the healthcare provider can ascertain if the need for the opioid medication is real or if the patient is just seeking opioid drugs to misuse. By requiring a urine drug test prior to prescribing an opioid medication, the healthcare provider can determine that the patient is not currently taking prescription or recreational controlled substances.
 
Pain syndromes are common in patients with multiple sclerosis. Data suggests that approximately one-half of patients with multiple sclerosis experience chronic pain. It is important to understand that not all pain caused from multiple sclerosis can be treated with opioid medications.

• Neuropathic pain is the most commonly reported type of pain experienced by people with MS. It is caused from the demyelination of nerves that is the hallmark of multiple sclerosis. People describe neuropathic pain as burning, aching, or electric pain. Neuropathic pain primarily affects the legs and feet, but can also affect the trunk and arms. Data suggests that anticonvulsant medications and antidepressant medications are the best treatment for neuropathic pain. Opioid medications are not effective in treating neuropathic pain.

• Spasticity, which is also common in MS patients, results from muscle cramps and spasms. Antispasticity medications and stretching exercises are the treatments of choice for pain secondary to spasticity. Opioid medications are not effective in treating pain secondary to spasticity.

• Musculoskeletal pain (or non-neuropathic pain) can occur in patients with or without multiple sclerosis. It is most often caused by an injury to the bones, joints, muscles, tendons, or ligaments from events such as jerking movements, car accidents, falls, fractures, sprains, and or dislocations. Opioid medications are sometimes used to treat musculoskeletal pain.
 
For more information on the use of opioids for chronic pain:

• The Centers for Disease Control and Prevention: www.cdc.gov/drugoverdose
• Journal of the American Medical Association Patient Pages: Go to the patient page link on JAMA’s website at www.jama.com. On this link there is a patient page title, Opioids for Chronic Pain.