Objective Evidence of Severe Disease: Opioid Use in Chronic Pain

John A. Zweifler

doi:10.1370/afm.1375

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An Ounce of Cure
John A Zweifler

Published on: 07 August 2012
An Ounce of Prevention...
Jacob P Prunuske

Published on: 19 July 2012

Published on: (7 August 2012)
Page navigation anchor for An Ounce of Cure
An Ounce of Cure
John A Zweifler, Deputy Medical Executive
Prunuske points out that access to prevention and treatment modalities that address social conditions influencing many of our behaviors,including use and abuse of opioids, are limited. Cutbacks in government spending suggest this lack of resources is unlikely to change anytime soon. As family physicians, we are oriented towards comprehensive approaches as indicated by the accompanying article in this issue exploring th...
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Prunuske points out that access to prevention and treatment modalities that address social conditions influencing many of our behaviors,including use and abuse of opioids, are limited. Cutbacks in government spending suggest this lack of resources is unlikely to change anytime soon. As family physicians, we are oriented towards comprehensive approaches as indicated by the accompanying article in this issue exploring the link between depression and chronic pain. (1) However, at present we must rely on our clinical skills with little available assistance for the range of mental health and substance abuse services that Prunuske rightly recommends we employ. Objective evidence of severe disease is a measure that physicians can apply when deciding to prescribe chronic opioids until more comprehensive preventive and treatment services are available. The extreme risks and dangers associated with chronic opioids demands a more rigorous standard for their use. Just as we require objective evidence before determining someone is disabled, we should expect the same before prescribing chronic opioids.
1.Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med. 2012;10(4):304 -311.
Competing interests: None declared
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Competing Interests: None declared.
Published on: (19 July 2012)
Page navigation anchor for An Ounce of Prevention...
An Ounce of Prevention...
Jacob P Prunuske, Family Physician
Dr. Zweifler highlights in his article the challenges of treating chronic pain, but does not address the importance of prevention. He discusses the lack of objective measures of pain, the limitations of existing guidelines, and the risks of opioid misuse and diversion. He proposes using the presence or absence of objective evidence of severe disease to guide rational use of opioids in chronic pain management. While i...
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Dr. Zweifler highlights in his article the challenges of treating chronic pain, but does not address the importance of prevention. He discusses the lack of objective measures of pain, the limitations of existing guidelines, and the risks of opioid misuse and diversion. He proposes using the presence or absence of objective evidence of severe disease to guide rational use of opioids in chronic pain management. While important, the use of objective evidence does not address the suffering of those who do not 'qualify' as having severe disease. Many patients use chronic opioids despite limited evidence of effectiveness, and many health care providers have experienced the reluctance of patients to stop opioids despite a lack of objective clinical improvement. Some patients subjectively perceive a benefit to opioid use, regardless of a provider's ability to quantify that benefit. I believe a greater emphasis must be placed on preventing the development of chronic pain. Research must be devoted to identifying the multitude of health determinants that contribute to the development of chronic pain. Resources must be devoted to developing integrated prevention systems within communities. Many patients lack access to integrated primary care, mental health care, substance abuse treatment, and appropriate specialty care. Many patients lack family and social support, vocational training, adequate housing and other resources to achieve or maintain health. Like most aspects of the health in the United States, our approach to chronic pain is fragmented, unpredictable, and inefficient and we suffer the consequences. While I too hold out hope for an objective measure of pain, I believe a greater focus on the prevention of chronic pain is warranted.
Competing interests: None declared
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Competing Interests: None declared.