Long-term opioid therapy reconsidered

Abstract

In the past 20 years, primary care physicians have greatly increased prescribing of long-term opioid therapy. However, the rise in opioid prescribing has outpaced the evidence regarding this practice. Increased opioid availability has been accompanied by an epidemic of opioid abuse and overdose. The rate of opioid addiction among patients receiving long-term opioid therapy remains unclear, but research suggests that opioid misuse is not rare. Recent studies report increased risks for serious adverse events, including fractures, cardiovascular events, and bowel obstruction, although further research on medical risks is needed. New data indicate that opioid-related risks may increase with dose. From a societal perspective, higher-dose regimens account for the majority of opioids dispensed, so cautious dosing may reduce both diversion potential and patient risks for adverse effects. Limiting long-term opioid therapy to patients for whom it provides decisive benefits could also reduce risks. Given the warning signs and knowledge gaps, greater caution and selectivity are needed in prescribing long-term opioid therapy. Until stronger evidence becomes available, clinicians should err on the side of caution when considering this treatment.

Conflict of interest statement

Potential Conflicts of Interest: Dr. Von Korff: Grant (money to institution): NIDA, NIA, Group Health Foundation; Grants/grants pending (money to institution): Johnson & Johnson. Dr. Deyo: Consulting fee or honorarium: UpToDate; Other: Board of Directors, Foundation for Informed Medical Decision Making. Dr. Chou: Grant: American Pain Society; Consulting fee or honorarium: American Pain Foundation. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum_M11-0929.