The Opioid Debate—Missing the Point

The substantial increase in opioid prescribing found in the US has legitimately raised questions about appropriate use and public health concerns. However, the myopic view point found in Ballantyne’s commentary “Is Lack of Evidence the Problem?” suggests that regulatory failure along with pharmaceutical industry promotional efforts is responsible for this increase. What is missing in this debate are alternate explanations. These include aging population, changing expectations of patients, regulatory pressures to improve pain management, and the risks along with the effectiveness of alternate nonopioid approaches to effective pain management. In the September issue of The Journal of Pain, Chapman et al published “Opioid Pharmacotherapy for Chronic Non-Cancer Pain in the United States: A Research Guideline for Developing an Evidence-Base” which provides a research outline that summarizes the wide gaps in knowledge that exist regarding the use of opioids in clinical practice for chronic noncancer pain. Here again, what is missing is the balance that is needed for a clinician to make informed decisions. No mention is made about analgesic alternatives which also can have significant toxicities such as NSAIDs. The need for comparative effectiveness research in this area is obvious. We agree completely that enhancing available mechanisms for outcomes research (especially with large-scale electronic recordkeeping systems) is highly desirable. Indeed, the future of opioid therapy will likely rest, to a substantial degree, on the results of this research. We would like to emphasize, however, that the current evidence is quite limited. Those who argue that long-term opioid therapy works well for all chronic pain patients, and those who argue that chronic opioid therapies “do not achieve the conventional goals of treatment”, are both making claims that go well beyond the available data. In Dr. Ballantyne’s editorial, the 2 citations for the contention that opioids do not achieve treatment goals in chronic pain patients are an opinion piece from Dr. Ballantyne herself, and a cross-sectional study of chronic pain patients in Denmark. Until such time as we have actual evidence from large-scale longitudinal studies of chronic opioid therapy for selected patients with specific pain conditions, let’s not commit the error of assuming we already know what such studies will reveal.