By Caroline Price
US experts call for more selective and cautious opioid prescribing for chronic noncancer pain in primary care, because of concerns over misuse of the drugs and continued uncertainty over when and for how long they should be prescribed.
In one of a clutch of related articles in the current Annals of Family Medicine, family doctors Dr Roger Rosenblatt and Dr Mary Catlin, from the University of Washington in Seattle, assert that "opioids for chronic noncancer pain are not appropriate therapy for most patients in primary care settings". They argue that there are safer alternative approaches to opioid therapy available, such as physical therapy, cognitive behavioural therapy, and treatment of co-occurring psychiatric illness.
A team led by Dr Mark Sullivan, also from the University of Washington, reports research showing that patients with moderate or severe depression, without any history of other substance misuse, are more likely than nondepressed patients to misuse opioid medications for nonpain symptoms, such as stress or insomnia. And even mildly depressed patients are more likely than those without depression to use higher doses of opioids than prescribed.
Dr John Zweifler from the University of California, San Francisco, meanwhile argues that opioids should only be initiated upon objective evidence of severe disease. But Rosenblatt and Catlin warn that the original trigger of chronic pain may no longer exist or be impossible to determine - and that sophisticated imaging techniques may lead to as many false-negative and false-positive diagnoses as the "much-maligned" visual analog pain scale.
Finally, Dr Michael Von Korff, from the Group Health Research Institute in Seattle, points out that guidelines on long-term use of opioids produced by palliative care specialists and "based almost entirely on expert opinion" have been generalised to primary care practice without proper evaluation.
"As the pendulum swings in the direction of more selective and conservative opioid prescribing, it is critical that primary care physicians take the leading role in defining how, when, and for whom opioids should be used in long-term management of chronic pain," concludes Dr Von Korff.
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