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Background Information

The American Academy of Neurology (AAN) is an association of more than 34,000 neurologists and neuroscience professionals dedicated to providing the best possible care for patients with neurologic conditions including migraine, chronic pain disorders, Alzheimer's disease, Parkinson's disease, stroke, epilepsy, ALS, multiple sclerosis, and traumatic brain injury.


Description of the Issue

The National Institutes of Health estimates that more than 11 percent of adults in the United States experiences chronic pain.1 Efforts to improve pain management resulted in a four-fold increase in the rate of opioid prescribing and a subsequent opioid epidemic. 12.5 million people misused prescription opioids in 2015 with 33,091 individuals dying from opioid overdose and an additional 12,989 people dying from heroin overdose.2

Neurologists are 14th among all medical specialties prescribing opioids.3 At the same time, a large number of patients with neurologic disease are using opioids and suffering from the effects of overuse and abuse.

The AAN supports the appropriate treatment of pain for neurologic patients living with pain. Pain disorders have a significant impact on a large number of patients. The mechanisms and treatment options for chronic pain are poorly understood and vastly understudied. There is insufficient evidence that opioids are effective for the treatment of chronic pain, particularly neuropathic pain, and clear evidence that they often worsen migraine.4 Further, there is limited research available on non-opioid therapies for pain. It may be acceptable to consider opioids for weakness, pain, or other symptoms at the end of life as part of a palliative care treatment plan. However, the risks of opioid therapy for most chronic conditions outweigh the benefits.

Greater funding for pain research is critical to developing appropriate pain therapies, improving treatment of chronic pain, and ultimately reducing opioid misuse, abuse, and overdose. In parallel, additional research is needed into how opioids impact the developing brain in cases of neonatal abstinence syndrome (NAS) and the recovering brain after injury in conditions such as traumatic brain injury and stroke. Specific pediatric research is especially important for infants in treatment for NAS and children and adolescents with traumatic brain injury. Patients and physicians need safe and effective treatment options that treat pain without creating the unnecessary potential for addiction or misuse. Dedicated funding for addiction and recovery services is also vital so that individuals who need help to overcome opioid addiction can stay on the path toward recovery.

In addition to research, standardized educational resources for prescribers, pharmacists, and patients are important for understanding safe and effective pain management and addiction prevention. Prescription monitoring programs are critical to promote responsible prescribing and prevent forgery. Interoperability with electronic health records and interstate information exchange would strengthen existing prescription monitoring programs, improve care coordination, and limit opportunities for trafficking.


The AAN Position

The AAN supports dedicated funding for research to understand pain, the impact of opioids on the developing and recovering brain, and the gaps in current addiction and recovery services.

The AAN encourages interoperability with electronic health records and prescription monitoring programs to promote responsible prescribing.

The AAN values science-based standardized resources for prescribers, pharmacists, and patients to make safe and informed medication decisions.


Rationale

Neurologists care for patients with chronic, complex conditions that include pain disorders like migraine, peripheral neuropathy, traumatic brain injury, multiple sclerosis, and low back pain. In addition, neurologists care for many patients with non-neurologic diagnoses treated by non-neurologists that suffer the consequences of opioid overuse and abuse. While science does not support the use of opioids for chronic pain, there are limited options for safe and effective non-opioid therapies for pain in neurologic conditions. This leaves physicians with few viable alternatives.

Patients living with traumatic brain injury are often prescribed multiple medications, including opioids, that can place patients at risk for misuse or even potentially slow the recovery process. More research is needed to understand the impact of analgesics on the recovering brain, so that therapies can be developed that promote healing.

Neurologists also frequently treat downstream effects of opioid misuse and abuse in cases of NAS, post-overdose stroke, cognitive decline, and worsening pain symptoms. Infants born with NAS have been exposed to opioids in utero and are often born addicted to these substances. They require extended hospitalization for withdrawal symptoms that can often take months of intensive hands-on care to subside. The primary treatments for these infants include methadone, morphine, and phenobarbital, and research has shown that these therapies have detrimental effects on developing brains. Infants with NAS and their parents may not have a regular physician who can provide appropriate care or addiction treatment and are at risk of falling through the cracks of the healthcare system if they move to a new state or need to transition their care to a new healthcare provider. Without educational resources and interoperability improvements to prescription monitoring programs, these patients will face unnecessary challenges in seeking care and addiction services.

As an example, the recent completion of phase III studies for calcitonin gene-related peptde (CGRP) pathway monoclonal antibodies as preventive treatments for migraine demonstrates that with sufficient investment in research medicines can be developed that reduce disability and burden.4, 5 Understanding the basis of pain disorders and thus targeting treatments produces better outcomes without unwanted side effects.

All patients deserve appropriate treatment for pain while minimizing the potential for addiction. Increased funding for pain research, dedicated funds for addiction services, and changes to promote interoperability in electronic health records and prescription monitoring programs can improve pain therapy and potentially eliminate the need for chronic opioid treatments that are fraught with risk for abuse and misuse.


Position Statement History

Drafted by Peter Goadsby, MD, PhD; James N. Goldenberg, MD, FAAN; Holly Hinson, MD, MCR; Mary Payne, MD; David B. Watson, MD, FAAN; Amber Stock, MPH (AAN Staff)


References

1 Nahin RL. Estimates of pain prevalence and severity in adults: United States, 2012. Pain 2015;16(8):769-780.

2 Frieden TR, Houry D. Reducing the Risks of Relief – the CDC Opioid Prescribing Guideline. NEJM 016;374:1501-1504.

3 Chen JH, Humphreys K, Shah NH, et al. Distribution of Opioids by Different Types of Medicare Prescribers. JAMA Internal Medicine 2016;176(2):259-261.

4 Bigal ME, Lipton RB. What predicts the change from episodic to chronic migraine? Curr Opin Neurol 2009; 22: 269-76.

5 Silberstein SD, Aycardi E, Bigal ME, Blankenbiller T, Dodick DW, Goadsby PJ, et al. Fremanezumab for chronic migraine preventive treatment. NEJM 2017;377:2113-22.

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