Seeking Balance Between Pain Relief and Safety

Pain is a symptom common tonumerousphysical andpsychiatric ailments andcanoftenbemanagedby treating theunderlyingcondition.However, inapproximately20millionpatients eachyear,chronicpainpersistsdespitetreatment.1,2Chronicpain is complex, heterogeneous, and poorly understood. Patientswithchronicpainexperience a decreased quality of lifeandincreasedrisk formultiplecomorbidities,costingsocietybillionsofdollars in reducedproductivityannually.Therefore,equippingphysicianswitheffectivetoolsandguidelinesfor chronic painmanagement is of paramount importance. Chronicpaincanbemanagedwithbothpharmacologicand nonpharmacologic options, such as behavioral and physical therapy. Unfortunately, insurance coverage for multidisciplinary painmanagement is limited,whichplacesmuchof the responsibility for treatingchronicpainonprimarycareandprescriptionmedications.Multiplepharmacologicoptionsareavailable, including nonsteroidal anti-inflammatory drugs, antidepressants, anticonvulsants, andopioids,but it is rarelypossible to predict the safest andmost effectivemedication for a given patient. Moreover, there is a paucity of clinical trials to guide physicians in treating chronic pain. In some cases, opioids are the only class ofmedications to which a patient responds, but becauseofdangerousadverseeffects, including respiratorydepression, unintentional overdose, and addiction, it is important for physicians, especially those inprimary care, to be confident with prescribing them safely. The clinical decision to prescribe opioids must also be made in the setting of increases in opioid prescriptions and prescription opioid–related deaths, which now exceed 200 million prescriptions and 16000 deaths per year (Figure). About half of those who died had an active opioid prescription; the other half obtained opioids through pill diversion.5 Notably, among diverted opioid prescriptions, more than 50% are obtained freely from a family member or friend with a valid prescription. This reality forces prescribing physicians to simultaneously address the risk for opioid overdose in their own patients, as well as the risk of prescriptions being diverted and harming others. Related article at jama.com Related article at jamainternalmedicine.com Figure. Opioid Prescriptions andOpioid-Related Deaths From 1999-2013