Opioid Prescribing: Can the Art Become More Science?

Abstract

There is controversy regarding the effectiveness and safety of long-term opioid therapy for the treatment of chronic pain. Since the 1980s, a four-fold increase in opioid prescribing has been correlated with a four-fold increase in unintentional opioid overdose deaths and a six-fold increase in substance abuse treatment admissions for prescription opioid addiction. 1 Unrealistic expectations by patients, patients’ families and providers regarding the benefits of opioids, and lack of understanding of the potential risks and harms complicate opioid prescribing. While not all patients with chronic pain improve on chronic opioid therapy, 2 some do. For those patients who do not respond, uncontrolled dose escalation often ensues, all in a desperate yet futile attempt to obtain pain relief. In this issue of JGIM, Becker and colleagues address important issues for the safe and effective use of opioids in treating chronic pain in primary care. 3 They suggest key areas of research aimed at reducing inappropriate prescribing. They begin by characterizing “appropriate ongoing opioid prescribing” and then identify quality improvement priorities, including: 1) developing brief, patient-administered screening checklists that incorporate items related to safety, efficacy and misuse; 2) developing treatment pathways to manage safety-related issues, low efficacy and problems related to misuse; and 3) promoting patient-centered, multimodal treatment plans. I agree with their characterization that appropriate prescribing should include measures of efficacy, safety and harm; however the devil is in the details. Measures of efficacy, safety and harm are subjective impressions of the patient and the provider, even when assessed using validated “objective” multidimensional scales such as the Brief Pain Inventory. 4 How much improvement in pain, functionand quality of life is enough to say the opioid treatment is efficacious for any given patient? Does a pain score that improves from 9 to 7 on a 10point scale warrant continued opioid therapy? Is walking an additional block to the store once per week enough functional