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Use of Opioids for Chronic Pain. A Recapitulation of the Science

Stephen E. Nadeau, MD¹ and Richard A. Lawhern, PhD²

Published 31 March 2023

Abstract

In recent years, the New England Journal of Medicine (NEJM) published an editorial by Andrew Kolodny and Robert Bhole that sought to reinforce the central premise of the CDC Guideline of 2016, which was updated in 2022. This premise, now long disproven, is that the primary cause of the opioid crisis and its continuation has been overprescribing of opioids by clinicians. We asked the editors of NEJM if they would consider an op-ed that presented the relevant science. They would not. This explicit editorial support by what is arguably the most prestigious journal of clinical medicine in the world indicated a strong need to recapitulate all of the scientific evidence that has been published regarding the use of opioids for chronic pain.

Keywords

opioid efficacy, opioid safety, opioid crisis, opioid trial design, CDC opioid guidelines, opioid dosage, opioid addiction

Introduction

In recent years, the New England Journal of Medicine (NEJM) published an editorial by Andrew Kolodny and Robert Bhole that sought to reinforce the central premise of the CDC Guideline of 2016, which was updated in 2022. This premise, now long disproven, is that the primary cause of the opioid crisis and its continuation has been overprescribing of opioids by clinicians. We asked the editors of NEJM if they would consider an op-ed that presented the relevant science. They would not. This explicit editorial support by what is arguably the most prestigious journal of clinical medicine in the world indicated a strong need to recapitulate all of the scientific evidence that has been published regarding the use of opioids for chronic pain.

Summary of the Science

Clinical experience testifies to the fact that opioids can be effective in treating chronic pain. However, the evidence is not as clear-cut as the CDC guidelines suggest. The guidelines were based on studies that did not adequately address the complexities of chronic pain management.

Have prescription opioids contributed to the national opioid overdose crisis? The answer is yes and no. Between 1999 and approximately 2011, pill mills, supplied by major drug distribution firms, distributed vast quantities of pharmaceutical-grade opioids to vulnerable populations, thereby creating a large population of people with drug addiction. Between 2010 and 2012, the states shut down the pill mills through direct enforcement of Prescription Drug Monitoring Plans (PDMP) at 50 states (now 60). PDMPs rendered opioid prescriptions more difficult to obtain, leading to a significant decrease in opioid prescriptions.

There is RCT evidence that the sole motivation for seeking opioid treatment by patients in pain is to achieve analgesia. This finding is entirely consistent with clinical experience. There is suggestive evidence that people with drug addiction use opioids and other drugs to achieve temporary oblivion to the conditions of their destitute and hopeless lives.

Author Contributions

SEN was primarily responsible for the conception of the article, the analyses, and writing this paper. RAL contributed to interpreting data published by CDC.

References

1. Kolodny A, Courtwright DT, Hellman ML. Screwed—how the prescription drug epidemic destroyed the prescription drug monitoring program. N Engl J Med. 2015;371:1100-1105. DOI: 10.1056/NEJMra2109111
2. Dowell D, Haegerich T, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016. MMWR Morb Mortal Wkly Rep. 2016;65:1-49. DOI: 10.15585/mmwr.6501e1.
3. Dowell D, Ragan KR, Jones CM, Baldwin GT, Chou R. CDC clinical practice guideline for prescribing opioids for pain—2022. MMWR Morb Mortal Wkly Rep. 2022;71(3):1-95. DOI: 10.15585/mmwr.mm7103a1.
4. Nadeau SE, Noyes J, Lawhern RA. Frequency of opioid exposure in patients with chronic pain: a national survey. Front Pain Res. 2022;721357.
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7. Zelaya CE, Sohi I, Lawhern RA. Opioid use and chronic pain. National Institute on Drug Abuse, NIH, ed. Available from: https://nida.nih.gov/publications/research-reports/opioids/opioid-use-chronic-pain.

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