Similar to treatments that carry substantial risks and must be used with great care, the drug group collectively known as opioid analgesics can be therapeutically desirable for treating severe acute pain, pain at the end of life, and other pain conditions in which the benefits of use outweigh the potential risks. Despite the need for cautious use of opioids, prescribing has become pervasive and excessive. Although opioids are one of many legitimate and diverse options for treating pain, they represent a large share of risk.
Chronic pain is a common reason patients seek medical care. A significant challenge in treating patients with chronic pain is that no perfect method exists to assess the existence or intensity of pain that a patient experiences. It remains impossible to prove that a patient does or does not have pain or pain relief. Prescribers with limited background in pain management and scarce resources may feel pressured to lean too heavily on opioids as the first or only option for chronic pain management. For many prescribers, pain management and opioids have become synonymous, as if prescribing opioids is equivalent to adequate pain management or withholding them were equivalent to undertreatment.
Over the past decade, interrelated public health trends have developed as a result of the prevalence of and difficulty in treating patients with pain syndromes. First, increased clinical attention was directed across all medical specialties to the undertreatment of pain. This was followed by more frequent and escalating prescribing of opioids. The improved comfort and quality of life seen with aggressive opioid therapy for patients with terminal cancer was extrapolated to patients with chronic pain. Moreover, predictions of safety with chronic use of opioids were founded on low-quality data. The increased availability of opioid medications was followed by a shift in patterns of drug abuse from illicit to prescription drugs—most notably a dramatic increase in diversion and nonmedical use of opioid pain medications within the United States. A paradigm shift is under way that emphasizes safety and a more limited role for opioids in overall chronic pain care. Major policy changes have also emerged that every prescriber should be well aware of.
Addiction and abuse are pivotal concerns associated with using opioids. However, opioids have a wide range of adverse effects that can result in serious morbidity and mortality. Additionally, opioid medications are not universally effective for all types of chronic pain or all patients.1 A major risk associated with opioids is respiratory depression resulting from unintended overdose. The risk for respiratory depression is heightened in older persons, those with mental illness, those with impaired renal or hepatic function, and individuals with cardiopulmonary disorders such as chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), and sleep apnea. Patients who combine opioids with other respiratory depressants such as alcohol, benzodiazepines, barbiturates, or sedative-hypnotics are also at increased risk for respiratory depression. Chronic opioid use also has a ...