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A Role for Opioids in Chronic Pain Management—Reply

A Role for Opioids in Chronic Pain Management—Reply In reply We thank McCarberg and colleagues for their thoughtful comments on the difficult issue of optimal use of opioids for patients with chronic pain. They make 2 general points, first that opioids in general and high-dose opioids specifically are not as dangerous as we claimed, and second, opioids are an effective treatment for chronic pain. McCarberg and colleagues state that overdose death is “an important but rare outcome” of opioid use and “probably only a secondary factor at most” in the cause of opioid overdose death. We respectfully disagree. The reference that MCarberg and colleagues provide to document that opioid use is a rare outcome is based on a large case-cohort study from the Veterans Health Association. In that study, the rate of opioid overdose death among patients taking any dose of opioids was estimated to be 0.04% over an approximately 3-year period.1 But the hazard ratio for patients taking dose equivalents of 100 mg or more of morphine compared with those taking low doses was 7.2, indicating that the rate of opioid overdose death among these patients was approximately 0.3%, or 3 opioid-related overdose deaths per 1000 patients per 3 years—1 per 1000 per year. Perhaps a death rate of 1 per 1000 per year would be acceptable if high-dose opioid treatment was highly effective for relief of chronic pain as McCarberg and colleagues claim. Studies suggest that short-term treatment of chronic pain (up to 16 weeks) reduces pain scores approximately 30%.2 There are no studies that document pain relief with long-term opioid treatment, which is the norm in clinical practice. We do not discount this benefit and agree that pain relief is much greater in some patients. However, in our experience, patients who require very high doses of opioids do not experience good pain relief—this is the reason that the dose has been escalated. We clearly recognize the need for treatment in the large number of patients who experience chronic pain. However, the treatments we use should result in more benefit than harm, and there is no good evidence that high-dose opioid treatment achieves this goal. We believe that physicians should focus more on treatments such as acetaminophen, nonsteroidal anti-inflammatory drugs, physical therapy, assistive devices, treatment of depression, substance use disorders, and other psychiatric illnesses—and less on the use of opioid drugs. Back to top Article Information Correspondence: Dr Grady, Department of Medicine, University of California, San Francisco, San Francisco VA Medical Center, 1635 Divisadero St, Ste 600, San Francisco, CA 94115 (Deborah.Grady@ucsf.edu). Financial Disclosure: None reported. References 1. Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-132121467284PubMedGoogle ScholarCrossref 2. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589-159416717269PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Internal Medicine American Medical Association

A Role for Opioids in Chronic Pain Management—Reply

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Publisher
American Medical Association
Copyright
Copyright © 2012 American Medical Association. All Rights Reserved.
ISSN
0003-9926
eISSN
1538-3679
DOI
10.1001/archinternmed.2012.1340
Publisher site
See Article on Publisher Site

Abstract

In reply We thank McCarberg and colleagues for their thoughtful comments on the difficult issue of optimal use of opioids for patients with chronic pain. They make 2 general points, first that opioids in general and high-dose opioids specifically are not as dangerous as we claimed, and second, opioids are an effective treatment for chronic pain. McCarberg and colleagues state that overdose death is “an important but rare outcome” of opioid use and “probably only a secondary factor at most” in the cause of opioid overdose death. We respectfully disagree. The reference that MCarberg and colleagues provide to document that opioid use is a rare outcome is based on a large case-cohort study from the Veterans Health Association. In that study, the rate of opioid overdose death among patients taking any dose of opioids was estimated to be 0.04% over an approximately 3-year period.1 But the hazard ratio for patients taking dose equivalents of 100 mg or more of morphine compared with those taking low doses was 7.2, indicating that the rate of opioid overdose death among these patients was approximately 0.3%, or 3 opioid-related overdose deaths per 1000 patients per 3 years—1 per 1000 per year. Perhaps a death rate of 1 per 1000 per year would be acceptable if high-dose opioid treatment was highly effective for relief of chronic pain as McCarberg and colleagues claim. Studies suggest that short-term treatment of chronic pain (up to 16 weeks) reduces pain scores approximately 30%.2 There are no studies that document pain relief with long-term opioid treatment, which is the norm in clinical practice. We do not discount this benefit and agree that pain relief is much greater in some patients. However, in our experience, patients who require very high doses of opioids do not experience good pain relief—this is the reason that the dose has been escalated. We clearly recognize the need for treatment in the large number of patients who experience chronic pain. However, the treatments we use should result in more benefit than harm, and there is no good evidence that high-dose opioid treatment achieves this goal. We believe that physicians should focus more on treatments such as acetaminophen, nonsteroidal anti-inflammatory drugs, physical therapy, assistive devices, treatment of depression, substance use disorders, and other psychiatric illnesses—and less on the use of opioid drugs. Back to top Article Information Correspondence: Dr Grady, Department of Medicine, University of California, San Francisco, San Francisco VA Medical Center, 1635 Divisadero St, Ste 600, San Francisco, CA 94115 (Deborah.Grady@ucsf.edu). Financial Disclosure: None reported. References 1. Bohnert ASB, Valenstein M, Bair MJ, et al. Association between opioid prescribing patterns and opioid overdose-related deaths. JAMA. 2011;305(13):1315-132121467284PubMedGoogle ScholarCrossref 2. Furlan AD, Sandoval JA, Mailis-Gagnon A, Tunks E. Opioids for chronic noncancer pain: a meta-analysis of effectiveness and side effects. CMAJ. 2006;174(11):1589-159416717269PubMedGoogle ScholarCrossref

Journal

Archives of Internal MedicineAmerican Medical Association

Published: May 28, 2012

Keywords: opioids,chronic pain management

References