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In this issue, Azevedo and colleagues [2] report infrequent use of opioids among Portuguese adults with chronic pain, concluding that liberal opioid prescribing for chronic pain is not a ubiquitous phenomenon. From 1980–2010, global consumption of strong opioids increased 30-fold, but with substantial cross-national differences. [25] In 2010, 693 milligrams (morphine equivalents) of strong opioids were prescribed per capita in the United States, compared to 154 milligrams in Portugal, but there is substantial variation in opioid prescribing even within the United States.[36]. On a volume basis, most opioids are prescribed by primary care physicians for long-term management of common chronic pain conditions.[6, 33] Large differences in opioid prescribing practices for chronic pain invite a question: Does more liberal opioid prescribing for long-term chronic pain management yield more or less favorable outcomes?

Opioids for chronic musculoskeletal pain: Putting patient safety first