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Editorials |

The Dueling Obligations of Opioid Stewardship

Phillip Coffin, MD, MIA; and Caleb Banta-Green, PhD
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 10 December 2013.

From San Francisco Department of Public Health, San Francisco, California; and University of Washington, Seattle, Washington.

Disclaimer: The authors are solely responsible for the content of this article, which does not necessarily represent the official views of the San Francisco Department of Public Health.

Potential Conflicts of Interest: None disclosed. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M13-2781.

Requests for Single Reprints: Phillip Coffin, MD, San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102; e-mail, pcoffin@gmail.com.

Current Author Addresses: Dr. Coffin: San Francisco Department of Public Health, 25 Van Ness Avenue, Suite 500, San Francisco, CA 94102.

Dr. Banta-Green: Alcohol and Drug Abuse Institute, University of Washington, 1107 Northeast 45th Street, Suite 120, Box 354805, Seattle, WA 98105-4631.

Ann Intern Med. 2014;160(3):207-208. doi:10.7326/M13-2781
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A position paper from the American College of Physicians in this issue discusses the public health problem created by prescription drug abuse. To achieve the dual goals of reducing iatrogenic opioid use disorders and protecting the ability to care for existing patients, the editorialists suggest several adjustments to opioid prescribing practice, including limiting the reasons for prescribing opioid medications and relying on functional status, rather than reported pain, as the metric of success for management of chronic, nonmalignant pain.

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Lack of evidence is lack of evidence
Posted on December 10, 2013
William M. Tierney, MD
President and CEO, Regenstrief Institute, Inc.
Conflict of Interest: None Declared
The authors state, "Long-term opioids for chronic nonmalignant pain may not improve and may in fact worsen functional status." The Cochrane review cited for this statement simply says there is insufficient evidence (specifically controlled trials comparing opioids to placebos or other drugs) to comment upon the efficacy and safety of opioids for low back pain. The authors have extended this Cochrane review to all non-malignant pain, and they have used the words "may not" and "may" to imply lack of effect of opioids and possible adverse effects. There is no evidence of association, let alone causation, of opioids with either positive or negative effects. Such lack of evidence should not be used to dissuade (or promote) the use of any drug. It should only be used to call for badly needed research, preferably a definitive, randomized, placebo-controlled trial of long-term opioids in chronic, non-malignant pain.
Evidence of harm, risks to inaction
Posted on March 22, 2014
Coffin PO, Banta-Green C
San Francisco Department of Public Health, University of Washington
Conflict of Interest: None Declared
We agree that there are insufficient data to support or refute potential benefits of longterm opioid use for chronic, nonmalignant pain. However, evidence of harm is not lacking. We will refrain from repeating the findings of the referenced American College of Physicians policy statement, but instead emphasize growing literature that has both brought into question potential benefits of longterm opioid therapy in this context and raised serious concerns about unintended adverse consequences at both population and individual levels (please pardon the reliance on few citations as we are limited by journal policies). In 2012 there were an estimated 4.8 million past month users and 1.9 million new users of prescription pain relievers for nonmedical purposes. The vast majority of the these medications came from prescriptions from single doctors, with as few as 2% from the practice commonly referred to as “doctor shopping”, and 0.2% from internet purchase.(1) Localities across the country have documented vast increases in prescription opioid overdose mortality, followed by rising rates of heroin overdose mortality. One study found that 39% of heroin users, on average 8 years younger, were initially dependent on prescription opioids, representing a new generation of heroin users.(2) A systematic review of opioid treatment for chronic back pain found no evidence of a benefit to longterm therapy and high rates of aberrant medication-taking behaviors.(3) Opioids are now generally discouraged for many other types of chronic pain, such as headaches(4) and fibromyalgia.(5) To be clear, this does not imply that opioids are never useful in these or other chronic pain syndromes, but rather that they are rarely a first line agent and they carry risks that we did not recognize 10 to 20 years ago.

Many providers already feel forced to restrict their use of opioids by legislation, regulators, payers, and clinic systems. Unfortunately, many of these changes carry real risks for our patients who are already dependent upon opioids, including undertreatment of pain that may respond to opioids as well as multiple harms related to illicit opioid use. Randomized studies of longterm opioid use are extremely challenging to conduct and results would take years – time policymakers are unlikely to grant in the setting of a perceived national emergency. If we do not step up as leaders by recognizing there is a problem and pursuing innovative yet humane practice reform now, we and our patients will pay a steep price.

1. Substance Abuse and Mental Health Services Administration. Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-41, HHS Publication No. (SMA) 11-4658. Rockville, MD: Substance Abuse and Mental Health Services Administration; 2013.
2. Peavy KM, Banta-Green CJ, Kingston S, Hanrahan M, Merrill JO, Coffin PO. "Hooked on" prescription-type opiates prior to using heroin: results from a survey of syringe exchange clients. J Psychoactive Drugs. 2012 Jul-Aug;44(3):259-65.
3. Martell BA, O'Connor PG, Kerns RD, Becker WC, Morales KH, Kosten TR, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146(2):116-27.
4. Levin M. Opioids in headache. Headache. 2014;54(1):12-21.
5. Skaer TL. Fibromyalgia: Disease Synopsis, Medication Cost Effectiveness and Economic Burden. Pharmacoeconomics. 2014.
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