Mitigating the Dangers of Opioids

JAMA InternalMedicinehas run a series of articles on thedangersofprescriptionopioids for the treatmentof chronicpain.1,2 Thebest solution is toavoidprescribingopioids forchronicpain because there is no high-quality evidence that they are effective for this indication, and the risk of adverse effects, including death from unintentional overdose, is great.3 But whenpatientsare inpain, andnonopioidmethodshaveproven ineffective, it can be difficult to send patients out of the office without an opioid prescription. Therefore, it is important to identify strategies to mitigate thedangers of opioids. In that regard, the article byMiller et al,4 is important because it demonstrates that there is less danger toprescribing short-acting rather than long-actingopioids.Amongapopulationof veteranswith chronic pain, using pharmacy and administrative data and a propensity score to adjust for baseline differences, the authors found that the risk of unintentional overdose was more than twice as high among patients initiating long-acting vs short-acting prescription opioids. The risk of overdose was more than 5 times higher in the first 2 weeks following initiation of longacting opioid therapy. Although it is possible that the higher rate of unintentional overdose among those veterans who received longacting agents is due to confounding from some unmeasured variable, itwouldbewise toavoid long-actingagentswhen initiating opioid therapy for chronic pain. It is also important to avoid high doses of opioids.1 Meanwhile, there is an urgent need for better nonopioid treatments for chronic pain.