Oversimplifying Opioid Misuse Disorder Confounds the Issue

At the recent International Association for the Study of Pain World Congress on Pain in Yokohama, Japan, colleagues from Europe, Asia, Australia, and Latin America commented on opioid misuse in the United States only slightly less frequently than they postulated on who will come out of the presidential debates less bloodied and become our next president. Several of these highly educated and sophisticated colleagues observed that mistruths and support for conceptions proven to be false appear equally in the statements of our presidential candidates and those of ideologically committed pro- and anti-opioid pain clinicians.

Both truths and mistruths often are promulgated by persons who believe that restricting opioid availability is a solution to the opioid misuse problem as well as by persons who believe that any such restrictions will cause many patients to suffer unnecessarily. Without question, too many opioids are in distribution. Evidence suggests that a major reason for this is prescribers giving patients several days to weeks of opioid pharmacotherapy for indications that may need only a day or two of the drug if the drugs are needed at all. Common examples include opioids being routinely prescribed following dental work, which usually responds better to nonsteroidal anti-inflammatory drugs (NSAIDs) than opioids, and the prescribing of 10 to 20 days of an opioid following relatively minor surgery to minimize telephone calls to the surgeon postoperatively. Unquestionably, aggressive marketing of single-source opioid dosage forms to primary care clinicians contributes to the prescribing of those drugs that often are not the opioids of choice for the patients who receive them.

In an attempt to provide balance in this debate, the journal invited Dr. Willem Scholten, a member of the journal editorial board, who was formerly Team Leader, Access to Controlled Medicines, and Secretary of the Expert Advisory Panel on Drug Dependence at the World Health organization (WHO), to write a balanced article on the issue. Willem asked Dr. Jack E. Henningfield, Adjunct Professor of Psychiatry and Behavioral Science at the Johns Hopkins University and Vice President for Research in Health Policy and Abuse Liability at Pinney Associates in Bethesda, Maryland, to be his co-author. Willem and Jack also consulted with other thought leaders in controlled substance/drug policy to assure that their positions were balanced and supported by data. The paper they wrote, entitled “Negative Outcomes of Unbalanced Opioid Policy Supported by Clinicians, Politicians, and the Media,”¹ is, in the opinion of this editor, the single best balanced publication on the topic.

Reader reaction to the article was largely positive. However, soon after the paper appeared, we received a letter from Dr. Andrew Kolodny, executive director and co-founder of Physicians for Responsible Opioid Prescribing (PROP), an organization with a mission to reduce morbidity and mortality caused by overprescribing of opioid analgesics. PROP is perhaps the most vocal and visible national organization advocating restriction on opioid availability to address opioid misuse. Dr. Kolodny's letter, entitled “Chronic Pain Patients Are Not Immune to Opioid Harms,”² appears in this issue of the journal. That letter contains some factual information, but it also asserts that Scholten and Henningfield made untrue assertions in their article.

Scholten and Henningfield submitted a response to the Kolodny letter entitled “Response to Kolodny: Negative Outcomes of Unbalanced Opioid Policy Supported by Clinicians, Politicians, and the Media.”³ They document their assertions and their refutation of Dr. Kolodny's negative claims with data.

We leave it to our readers to decide which argument they support. As stated above, truths are advocated by both those who oppose and those who promote opioid availability for the management of chronic pain. Some—not all—would argue that limitations on the use of these strong medications by primary care clinicians with limited training and experience in their use may be warranted, as advocated in the recent guideline from the US Centers for Disease Control and Prevention (CDC) entitled “CDC Guideline for Prescribing Opioids for Chronic Pain.”⁴ But it is important to note that this guideline is explicitly addressed to and intended for primary care clinicians, not those with more expertise in pain management and opioid pharmacotherapy. It is most regrettable that many policy makers, regulators, and even clinicians believe that the guideline applies to all prescribers and use it to support broad-based opioid restriction.

Chronic pain is not a simple, unidimensional issue; it often requires multiple approaches for effective management. The evidence is clear that interdisciplinary care of chronic pain is usually superior to single modality interventions,^5,6 and there is broad agreement that opioid pharmacotherapy alone is not a rational approach to the management of difficult pain.⁷

Advocating simple solutions to complex problems is attractive. But it does not lead to the best outcomes. The journal supports a balanced and evidence-based approach to the opioid overuse and misuse problem that currently plagues American society. We encourage all readers to do the same.