Opioid Prescription For Chronic Pain Research Articles

Overdose and suicide are different phenomena among opioid users that require different clinical management.

Given the high rates of mental health comorbidity among opioid users, and increasing rates of opioid prescription for chronic pain, psychiatrists and mental health clinicians are likely to treat patients who are dependent on opioids. Among such patients, many will have histories of opioid overdose or suicide attempts. It is tempting to assume that these are related behaviours and that 'accidental' overdoses are actually suicide attempts. We provide evidence here to demonstrate that while some overdoses are intentional, most are not. More than half of deaths among opioid users are due to unintentional overdose. Suicides constitute a minority: less than 10% of heroin user deaths are estimated to be due to suicide, as are 20-30% of prescribed opioid fatalities. Moreover, suicide attempts are more commonly made using means other than opioids. Overdose and suicide among opioid dependent patients are two distinct phenomena, associated with different risk factors, that need to be separately assessed and their respective risk managed.

A Shift Left: Revised Regulations for Opioid Prescribing in New Jersey

ABSTRACT The opioid epidemic has caused devastation in both the state of New Jersey and the nation, highlighting the need to make opioid prescribing practices safer. Preventing unnecessary initiation of opioids and ensuring opioid therapy is discontinued when appropriate are necessary parts of combating the opioid epidemic. To give prescribers a framework to provide the safest and most effective care, in February 2021 the New Jersey State Board of Medical Examiners unanimously approved proposed updates to opioid-prescribing regulations in the state. The updated prescribing regulations in New Jersey ensure patients who receive an opioid prescription for chronic pain have the assurance of a treatment plan, an assessment of risks, and monitoring for benefits and harms of therapy. This approach preserves access to care for patients in need while minimizing risks of abuse, diversion, and addiction. New regulations define treatment plans and require specific documentation for health care providers (HCPs) treating patients with chronic pain, giving HCPs tools to prescribe safely. The success of the regulatory updates can be measured by decreases in new cases of opioid-use disorder (OUD) and overdose deaths throughout New Jersey. New Jersey's updated regulations can serve as a model with nationwide applicability.

Long-term, high-dose opioid prescription for chronic non-cancer pain in primary care: an observational study.

Opioid prescriptions for chronic pain have risen sharply over the last 25 years; harms associated with these drugs are related to dose and length of use. The main aim of this study was to identify patients prescribed long-term, high-dose (LTHD) opioids in the community and to assess the prevalence of such use. An observational study of opioid prescribing in two demographically dissimilar GP practices in North Wales, UK. Details of opioid prescriptions were collected for 22 841 patients, of whom 1488 (6.5%) were being prescribed opioids on the census date. Exhaustive examination of the data identified all patients who were prescribed oral morphine equivalent doses of ≥120 mg/day for ≥1 year. All these patients were being prescribed ≥120 mg/day, as a single drug, morphine, oxycodone, fentanyl, or buprenorphine, irrespective of opioid polypharmacy. Across both practices, 1.71/1000 patients were identified as LTHD users of opioid medication for chronic non-cancer pain (CNCP). Prevalence was similar in the two practices. Repetition of the process until January 2021 showed no change in the pattern. This study offers confirmation that a significant group of patients are prescribed long-term opioid medication for chronic pain at doses that are unlikely to be effective in reducing pain, but are likely to have harmful consequences. The findings offer a simple, reliable, and practical method of data extraction to identify these patients individually from routinely collected prescribing data, which will help in monitoring and treating individuals and establishing the problem prevalence.

Diagnosing Prescription Opioid Use Disorder in Patients Using Prescribed Opioids for Chronic Pain.

The diagnostic criteria for opioid use disorder, originally developed for heroin, did not anticipate the surge in prescription opioid use and the resulting complexities in diagnosing prescription opioid use disorder (POUD), including differentiation of pain relief (therapeutic intent) from more common drug use motives, such as to get high or to cope with negative affect. The authors examined the validity of the Psychiatric Research Interview for Substance and Mental Disorders, DSM-5 opioid version, an instrument designed to make this differentiation. Patients (N=606) from pain clinics and inpatient substance treatment who ever received a ≥30-day opioid prescription for chronic pain were evaluated for DSM-5 POUD (i.e., withdrawal and tolerance were not considered positive if patients used opioids only as prescribed, per DSM-5 guidelines) and pain-adjusted POUD (behavioral/subjective criteria were not considered positive if pain relief [therapeutic intent] was the sole motive). Bivariate correlated-outcome regression models indicated associations of 10 validators with DSM-5 and pain-adjusted POUD measures, using mean ratios for dimensional measures and odds ratios for binary measures. The prevalences of DSM-5 and pain-adjusted POUD, respectively, were 44.4% and 30.4% at the ≥2-criteria threshold and 29.5% and 25.3% at the ≥4-criteria threshold. Pain adjustment had little effect on prevalence among substance treatment patients but resulted in substantially lower prevalence among pain treatment patients. All validators had significantly stronger associations with pain-adjusted than with DSM-5 dimensional POUD measures (ratios of mean ratios, 1.22-2.31). For most validators, pain-adjusted binary POUD had larger odds ratios than DSM-5 measures. Adapting POUD measures for pain relief (therapeutic intent) improved validity. Studies should investigate the clinical utility of differentiating between therapeutic and nontherapeutic intent in evaluating POUD diagnostic criteria.

Anxiety, Depression, and Opioid Misuse Among Adults With Chronic Pain: The Role of Anxiety Sensitivity.

The opioid epidemic is a significant public health problem largely driven by opioid prescriptions for chronic pain. Among those with chronic pain, anxiety and depressive symptoms have been linked to opioid misuse, and individual differences in anxiety and depressive symptoms among adults with chronic pain may be important for better understanding pain. Yet, little work has examined mechanisms that may link anxiety and depressive symptoms to opioid misuse among adults with chronic pain. Anxiety sensitivity (AS), or the fear of anxiety-related physical sensations, may be one candidate construct that has been linked independently to anxiety and depressive symptoms as well as opioid misuse. The current survey-based study examined the indirect association of AS in the relation between anxiety and depressive symptoms and opioid misuse among 429 adults with chronic pain currently using prescription opioid medication (73.9% female, Mage=38.32 y, SD=11.07). Using structural equation modeling, it appears that AS is a potential construct in the interrelation between anxiety and depressive symptoms and opioid misuse. However, an alternative model found equally strong empirical support, as mental health symptoms may serve as an explanatory factor between AS and opioid misuse. Bi-directional effects are apt to be involved among the studied variables. Prospective research is needed to replicate the study results and isolate the temporal patterning between the studied constructs. Nonetheless, the data overall highlight the importance of both AS and anxiety and depressive symptoms in terms of understanding opioid misuse among adults with chronic pain.

Integrated Behavioral Treatment for Veterans With Co-Morbid Chronic Pain and Hazardous Opioid Use: A Randomized Controlled Pilot Trial

Opioid prescription in the treatment of chronic pain is frequent and carries a risk of increased morbidity and mortality in a clinically significant number of patients, particularly those who are using opioids in a hazardous manner. Few treatment options are available that target both pain-related interference and hazardous opioid use among patients with chronic pain. In military Veterans, this issue is of particular importance as numerous reports indicate continued high rates of opioid prescription for chronic pain, as well as significant opioid-related problems. The overall aim of the present study was to determine the feasibility of an integrated psychosocial treatment in Veterans with chronic pain, who also have evidence of hazardous opioid use. To examine this aim, a random design was used to assess the feasibility and initial efficacy of integrating 2 empirically supported interventions: Acceptance and Commitment Therapy for chronic pain and Mindfulness Based Relapse Prevention for opioid misuse. Half of participants were randomized to the integrated treatment group and all participants received usual care through a Veteran's Administration co-occurring disorders medical clinic to treat chronic pain and opioid misuse. In total, 37 participants were randomized and included in intent-to-treat analyses and 32 individuals were included in per protocol analyses with 6-month follow-up serving as the primary study endpoint. Feasibility indicators included recruitment, retention, and treatment completion rates. Recruitment fell short of targeted enrollment, although retention and completion were excellent. Primary outcome measures were opioid misuse, pain interference, and pain behavior. Simultaneous multiple regression analyses controlled for pain duration, baseline opioid dose, and baseline value for outcome measures. Results of both the intent-to-treat and per protocol indicated a significant effect in favor of the integrated intervention for opioid misuse, pain interference, and pain behavior. Results support the feasibility of providing an integrated treatment for both opioid risk and pain interference. PerspectiveOpioid misuse occurs in some opioid-prescribed individuals with chronic pain. Few treatment options exist that target both pain interference and opioid misuse. This study examined feasibility and initial efficacy of an integrated behavioral treatment for Veterans. Feasibility was supported, except recruitment. Efficacy was supported compared to usual care.

Substitution of marijuana for opioids in a national survey of US adults.

Opioid prescriptions for chronic pain and subsequent opioid-related complications have risen dramatically in the US. Recent data suggest that medical marijuana laws have been associated with lower state-level opioid overdose mortality. In a national survey, we examined the prevalence of substitution of marijuana for opioids among US adults taking opioids for pain.Using GfK’s KnowledgePanel, we conducted an Internet-based survey of a nationally representative sample of 16,280 adults in 2017 about individual perceptions and use of marijuana. We developed questions designed to assess the extent and reasons for substitution of marijuana for opioids. We examined opioid substitution among respondents with a history of ever using marijuana who used opioids in the past 12 months. There were 9,003 respondents, corresponding to a 55.3% response rate. The mean age was 48 years. Among the 5% (n = 486) who reported ever using marijuana and using opioids in the past year, 43% used opioids daily, and 23% reported current (past 30 day) marijuana use. Forty-one percent reported a decrease or cessation of opioid use due to marijuana use; 46% reported no change in opioid use; and 8% reported an increase in opioid use. We found that a substantial number of US adults reported that they substituted marijuana for opioids.

(231) Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: A Collaborative Health Outcomes Information Registry (CHOIR) study

(231) Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: A Collaborative Health Outcomes Information Registry (CHOIR) study

Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: a Collaborative Health Outcomes Information Registry study.

Background and purposePerceived injustice has been defined as an appraisal regarding the severity and irreparability of loss associated with pain, blame and a sense of unfairness. Recent findings have identified perceived injustice as an important risk factor for pain-related outcomes. Studies suggest that perceived injustice is associated with opioid prescription in patients with pain conditions. However, the mechanisms by which perceived injustice is linked to opioid prescription are not well understood. The primary objective of this study was to examine the potential mediating roles of pain intensity, depressive symptoms and pain behavior in the association between perceived injustice and opioid prescription among patients with chronic pain.MethodsThis cross-sectional study used a sample of 344 patients with chronic pain being treated at a tertiary pain treatment center. Participants completed measures of perceived injustice, pain intensity, depressive symptoms, pain behavior and opioid prescription. Bootstrapped multiple mediation analyses were used to examine the mediating role of patients’ pain intensity, depressive symptoms and pain behavior in the association between perceived injustice and opioid prescription.ResultsConsistent with previous research, we found a significant association between perceived injustice and opioid prescription. Interestingly, results revealed that pain behavior was the only variable that mediated the association between perceived injustice and opioid prescription.ConclusionThis study was the first to examine the mechanisms by which perceived injustice is associated with opioid prescription in patients with chronic pain. We found that pain behavior, rather than pain intensity and depressive symptoms, mediated the association between perceived injustice and opioid prescription. Future research in this area should employ a longitudinal research design in order to arrive at clearer causal conclusions about the relationships between pain behavior, perceived injustice and opioid prescription.

Protecting the infant from unknown risks.

Dr. Dalal cites literature and guidelines for minimizing the effects of short-term postpartum opioid use, with several studies reporting that single-dose administration may have no detrimental effects on the neonate. In the case of opioid prescription for chronic pain, repeated doses and long-term use are likely. Dr. Dalal notes that caution should be advised in nursing mothers who require repeated opioid dosing. The question is how one interprets “caution.” While the literature often cites careful monitoring for infant drowsiness or other indices of central nervous system depression, these recommendations are predicated on the assumptions that any risks are transitory and minimal as long as …

OR09-1 * COGNITIVE IMPULSIVITY AND CHRONIC OPIOID USE

Introduction. Previous studies have provided inconsistent evidence that chronic exposure to opioid drugs, including heroin and methadone, may be associated with impairments in executive neuropsychological functioning, specifically cognitive impulsivity. Methods. Participants with validated histories of illicit heroin use (n = 24), former heroin users stabilised on prescribed methadone maintenance treatment (MMT) (n = 29), licit opioid prescriptions for chronic pain without history of abuse or dependence (n = 28) and healthy controls (n = 28) were recruited and tested on measures of cognitive impulsivity, motor impulsivity and non-planning impulsivity. Results. Stable illicit heroin users showed increased motor impulsivity and impaired strategic planning. Additionally, they placed higher bets earlier and risked more. MMT participants deliberated longer and placed higher bets earlier but did not risk more. Chronic opiate exposed pain participants did not differ from healthy controls on any measures on any tasks. Conclusion. These data support the hypothesis that different aspects of neuropsychological measures of impulsivity appear to be associated with exposure to different opioids and also to the syndrome of opioid dependence. This could reflect either a neurobehavioural consequence of opioid exposure, or may represent an underlying trait vulnerability to opioid dependence.

Correlates of Prescription Opioid Initiation and Long-term Opioid Use in Veterans With Persistent Pain

Little is known about how opioid prescriptions for chronic pain are initiated. We sought to describe patterns of prescription opioid initiation, identify correlates of opioid initiation, and examine correlates of receipt of chronic opioid therapy (COT) among veterans with persistent noncancer pain. Using Veterans Affairs administrative data, we identified 5961 veterans from the Pacific Northwest with persistent elevated pain intensity scores who had not been prescribed opioids in the prior 12 months. We compared veterans not prescribed opioids over the subsequent 12 months with those prescribed any opioid and to those prescribed COT (>90 consecutive days). During the study year, 35% of the sample received an opioid prescription and 5% received COT. Most first opioid prescriptions were written by primary care clinicians. Veterans prescribed COT were younger, had greater pain intensity, and high rates of psychiatric and substance use disorders compared with veterans in the other 2 groups. Among patients receiving COT, 29% were prescribed long-acting opioids, 37% received 1 or more urine drug screens, and 24% were prescribed benzodiazepines. Adjusting for age, sex, and baseline pain intensity, major depression [odds ratio 1.24 (1.10-1.39); 1.48 (1.14-1.93)], and nicotine dependence [1.34 (1.17-1.53); 2.02 (1.53-2.67)] were associated with receiving any opioid prescription and with COT, respectively. Opioid initiations are common among veterans with persistent pain, but most veterans are not prescribed opioids long-term. Psychiatric disorders and substance use disorders are associated with receiving COT. Many Veterans receiving COT are concurrently prescribed benzodiazepines and many do not receive urine drug screening; additional study regarding practices that optimize safety of COT in this population is indicated.

Opioid Doses and Increased Risk for Overdose

Letters6 July 2010Opioid Doses and Increased Risk for OverdoseMilap C. Nahata, PharmD, MS and Katy E. Trinkley, PharmDMilap C. Nahata, PharmD, MSFrom Ohio State University, Columbus, OH 43210.Search for more papers by this author and Katy E. Trinkley, PharmDFrom Ohio State University, Columbus, OH 43210.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-153-1-201007060-00017 SectionsAboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:We commend Dunn and colleagues (1) on their findings of a dose–response relationship between opioid dose and overdose risk. Although some participants misused opioids, most had not received opioids for at least 6 months. The authors found that opioid doses of 20 mg/d were associated with lower potential for overdose than higher doses. The daily doses reported were the cumulative dose dispensed over 90 days, divided by 90, with no indication of the prescribed duration. All participants filled at least 3 opioid prescriptions, but the daily supply was not reported. This may lead to misinterpretation of their ...Reference1. Dunn KM, Saunders KW, Rutter CM, Banta-Green CJ, Merrill JO, Sullivan MD, et al. Opioid prescriptions for chronic pain and overdose: a cohort study. Ann Intern Med. 2010;152:85-92. [PMID: 20083827] LinkGoogle Scholar Author, Article, and Disclosure InformationAffiliations: From Ohio State University, Columbus, OH 43210.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoOpioid Prescriptions for Chronic Pain and Overdose Kate M. Dunn , Kathleen W. Saunders , Carolyn M. Rutter , Caleb J. Banta-Green , Joseph O. Merrill , Mark D. Sullivan , Constance M. Weisner , Michael J. Silverberg , Cynthia I. Campbell , Bruce M. Psaty , and Michael Von Korff Opioid Doses and Increased Risk for Overdose Michael Von Korff and Kate Dunn Opioid Doses and Increased Risk for Overdose William C. Becker , David A. Fiellin , and Robert D. Kerns Metrics 6 July 2010Volume 153, Issue 1Page: 59KeywordsConflicts of interestMorphineOpioids ePublished: 6 July 2010 Issue Published: 6 July 2010 CopyrightCopyright © 2010 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...

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Opioid prescriptions for chronic pain and overdose: a cohort study.

Long-term opioid therapy for chronic noncancer pain is becoming increasingly common in community practice. Concomitant with this change in practice, rates of fatal opioid overdose have increased. The extent to which overdose risks are elevated among patients receiving medically prescribed long-term opioid therapy is unknown. To estimate rates of opioid overdose and their association with an average prescribed daily opioid dose among patients receiving medically prescribed, long-term opioid therapy. Cox proportional hazards models were used to estimate overdose risk as a function of average daily opioid dose (morphine equivalents) received at the time of overdose. HMO. 9940 persons who received 3 or more opioid prescriptions within 90 days for chronic noncancer pain between 1997 and 2005. Average daily opioid dose over the previous 90 days from automated pharmacy data. Primary outcomes--nonfatal and fatal overdoses--were identified through diagnostic codes from inpatient and outpatient care and death certificates and were confirmed by medical record review. 51 opioid-related overdoses were identified, including 6 deaths. Compared with patients receiving 1 to 20 mg/d of opioids (0.2% annual overdose rate), patients receiving 50 to 99 mg/d had a 3.7-fold increase in overdose risk (95% CI, 1.5 to 9.5) and a 0.7% annual overdose rate. Patients receiving 100 mg/d or more had an 8.9-fold increase in overdose risk (CI, 4.0 to 19.7) and a 1.8% annual overdose rate. Increased overdose risk among patients receiving higher dose regimens may be due to confounding by patient differences and by use of opioids in ways not intended by prescribing physicians. The small number of overdoses in the study cohort is also a limitation. Patients receiving higher doses of prescribed opioids are at increased risk for overdose, which underscores the need for close supervision of these patients. National Institute of Drug Abuse.

Cautionary Guidelines for the Use of Opioids in Chronic Pain

Guidelines for the use of opioids in the treatment of chronic pain have recently been proposed by the American Academy of Addiction Psychiatry. Older guidelines proposed by American pain organizations had the effect of liberalizing opioid prescription. In recent years, dramatic increases in prescribed opioids have been followed by equally dramatic rises in morbidity and mortality from prescription opioids. In addition, new research has increased knowledge of the long-term effects of opioids. These new guidelines propose increased caution in regard to opioid prescription for chronic pain.

(814): Patterns of use and concern about opioid analgesia for chronic nonmalignant pain in general practice: A survey of physicians

Opioid prescriptions for chronic pain have increased dramatically during the last 20 years. However, research has shown that physicians are frequently reluctant to prescribe strong opioid medications and sometimes avoid them altogether. This study investigates physicians’ attitudes and beliefs regarding strong opioids and chronic pain in relation to their willingness to prescribe them. Questionnaires (N=1,192) were sent to primary care physicians in southwest England. Following standard mail survey methods the response rate was 35% (N=414).

Drs. Streltzer and Johansen Reply

Back to table of contents Previous article Next article Letters to the EditorFull AccessDrs. Streltzer and Johansen ReplyJon Streltzer M.D.,Luther Johansen M.D.,Jon Streltzer M.D.Search for more papers by this author,Luther Johansen M.D.Search for more papers by this author,Published Online:1 Jul 2006AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail To the Editor: The case we presented illustrates how nonevidence-based medical attitudes influenced opioid use in a chronic pain patient (1) . In our experience, our study case is far from unique and, with increasing frequency, similar cases are being referred to psychiatrists after opioid dependence has been established. In our discussion, we reviewed the current evidence suggesting that chronic intake of high-dose opioids is neither effective nor safe in the treatment of persistent pain and that it likely enhances pain sensitivity in general. Despite his acknowledgment of the latter, Dr. Abramson advocates a divergent approach toward opioid prescription for chronic pain. He describes a dichotomy to explain differences in chronic pain patients, implying that this dichotomy should determine whether high-dose opioids might be appropriate. He argues that one group of patients has “true” pain and therefore does not have drug-seeking behavior, and another group is prone to addictive behavior. This is consistent with the literature that distinguishes addiction from dependence, which implies that if a patient behaves well, maintenance opioid treatment is appropriate. In the case we presented, several physicians at different times, ranging from months to years, perceived the patient as physically dependent on opioids, but not addicted to them, and that high-dose opioids were necessary to control her pain. However, the complete, longitudinal course demonstrated the tragedy of this approach. Advocacy of maintenance opioid treatment for dependent chronic pain patients but not for addicted pain patients is based on an underlying assumption: that the body’s response to chronic intake of opioids is similar to acute intake in that effective analgesia is maintained despite physical dependence. There is strong and growing evidence on clinical, experimental, and basic scientific grounds that this assumption is false (2 , 3) . Nevertheless, good functioning can be compatible with high-dose opioid intake, such as with methadone maintenance patients treated for heroin or other opioid addiction. Therefore, the fact that some chronic pain patients are capable of functioning relatively well on high-dose opioids for lengthy periods of time does not prove that opioid analgesia is responsible. Dr. Abramson suggests that treatment involving detoxification is not likely to be beneficial for nondrug abusing patients with chronic nonmalignant pain who are maintained on high-dose opioids. We have found the opposite to be true, and so have others (4) . Dr. Abramson expresses confidence that he can sort out a subset of patients who will benefit from opioid maintenance. This desirable ability is not common enough, judging from the epidemic of prescription opioid problems that has accompanied the liberal prescribing of recent years (5) . Honolulu, HawaiiLandstuhl, GermanyReprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.

Drs. Streltzer and Johansen Reply

Back to table of contents Previous article Next article Letters to the EditorFull AccessDrs. Streltzer and Johansen ReplyJon Streltzer M.D.,Luther Johansen M.D.,Jon Streltzer M.D.Search for more papers by this author,Luther Johansen M.D.Search for more papers by this author,Published Online:1 Jul 2006AboutSectionsView articlePDFView EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail View article To the Editor: The case we presented illustrates how nonevidence-based medical attitudes influenced opioid use in a chronic pain patient (1) . In our experience, our study case is far from unique and, with increasing frequency, similar cases are being referred to psychiatrists after opioid dependence has been established. In our discussion, we reviewed the current evidence suggesting that chronic intake of high-dose opioids is neither effective nor safe in the treatment of persistent pain and that it likely enhances pain sensitivity in general. Despite his acknowledgment of the latter, Dr. Abramson advocates a divergent approach toward opioid prescription for chronic pain. He describes a dichotomy to explain differences in chronic pain patients, implying that this dichotomy should determine whether high-dose opioids might be appropriate. He argues that one group of patients has “true” pain and therefore does not have drug-seeking behavior, and another group is prone to addictive behavior. This is consistent with the literature that distinguishes addiction from dependence, which implies that if a patient behaves well, maintenance opioid treatment is appropriate. In the case we presented, several physicians at different times, ranging from months to years, perceived the patient as physically dependent on opioids, but not addicted to them, and that high-dose opioids were necessary to control her pain. However, the complete, longitudinal course demonstrated the tragedy of this approach. Advocacy of maintenance opioid treatment for dependent chronic pain patients but not for addicted pain patients is based on an underlying assumption: that the body’s response to chronic intake of opioids is similar to acute intake in that effective analgesia is maintained despite physical dependence. There is strong and growing evidence on clinical, experimental, and basic scientific grounds that this assumption is false (2 , 3) . Nevertheless, good functioning can be compatible with high-dose opioid intake, such as with methadone maintenance patients treated for heroin or other opioid addiction. Therefore, the fact that some chronic pain patients are capable of functioning relatively well on high-dose opioids for lengthy periods of time does not prove that opioid analgesia is responsible. Dr. Abramson suggests that treatment involving detoxification is not likely to be beneficial for nondrug abusing patients with chronic nonmalignant pain who are maintained on high-dose opioids. We have found the opposite to be true, and so have others (4) . Dr. Abramson expresses confidence that he can sort out a subset of patients who will benefit from opioid maintenance. This desirable ability is not common enough, judging from the epidemic of prescription opioid problems that has accompanied the liberal prescribing of recent years (5) . Honolulu, HawaiiLandstuhl, GermanyReprints are not available; however, Letters to the Editor can be downloaded at http://ajp.psychiatryonline.org.