Opioids for Chronic Pain: First Do No Harm

In this editorial Dr. Rosenblatt summarizes by listing some facts:

1. The volume of prescribed opioids has increased 600% from 1997 to 2007.8
2. During roughly the same period, the number of unintentional lethal overdoses involving prescription opioids increased more than 350%, from approximately 4,000 in 1999 to more than 14,000 in 2007.9

3. Risk of overdose or death increases with higher doses of opioids, especially in patients who concurrently use other respiratory depressants such as benzodiazepines.10
4. There are treatments for chronic pain that are much safer than opioids, including, but not limited to, physical therapy, cognitive behavioral therapy, low-dose tricyclic medications, and treatment of co-occurring psychiatric illnesses.11,12
5. High doses of opioids do not reliably decrease patients' report of the magnitude of chronic pain, nor do they improve patients' overall health and function.13

I consider presentation of the facts an example of correlation without necessarily any connection with causation, and would hope that practice patterns would not be based on such a listing. Other causes of overdose and death can include patients with the disease of addiction switching to prescription opioids, with or without involvement of a prescribing physician, who with inadequate understanding of oral pharmacokinetics or the synergistic effects of drug combinations, inadvertently overdose because of this ignorance. We simply have insufficient understanding of the pathology and epidemiology of the increase in overdose and death which is correlated with the increase number of prescriptions for opioids.

I consider the conclusions based on the cited literature to be preliminary and also subject to inadequate examination of the situation. In particular studies to date focus on relatively short periods of treatment and use outcome measurements, which while considered validated, may be irrelevant to the multidimensional aspect of any individual patient's situation. I refer in particular to the use numeric or visual analog scales as opposed to functional or quality of life measurement. In my opinion the anesthesia literature has established that evaluation of the relative safety of any given therapeutic intervention is extraordinarily difficult and expensive.

I appreciate and respect the efforts of the author. I would suggest inclusion of additional statements emphasizing the ambiguity of the this very complex problem.
John Hexem

Competing interests: I receive consulting fees from DOCS Eudcation and royalties from Conscious Sedation Consulting, LLC