Dr. Adrian Bartoli, a pain specialist practicing in San Francisco, said he was disappointed that the authors of the review implied that patients who have had a prior problem with addiction should be excluded from opioid therapy for chronic noncancer pain. “There's nothing in this analysis that would suggest that. That was their opinion,” he said.
He also felt that the review muddled concepts of pain and addiction, referring to addiction in terms of tolerance and dependence, which are very different concepts.
“I got the sense that they felt that patients could be imbued with addiction by taking a medicine like a narcotic,” Dr. Bartoli said. “It's a genetically predisposed condition.”
On the other hand, he worried that the report of a very low rate of addiction may lead primary care physicians, in particular, to put patients with chronic noncancer pain on long-term opioids without sufficiently considering other remedies or medications.
“The pharmaceutical industry over the past 10 years has been incredibly strong in trying to move these narcotics onto the market and to put the primary care physicians at ease that they are not prescribing something that has a risk of addiction or abuse,” he said. “This review probably is going to reinforce that. Ultimately, there are pros and cons to that occurring.”
Primary care internist Dr. Roger Chou agreed, saying that the 0.3% rate of addiction reported is “a little misleading, because it's based on pretty crummy data.” The review's findings on addiction, pain relief, and adverse events apply to very select groups of patients, not the more complicated cases that raise concerns for physicians considering long-term opioids.
Mainly, the review shows how little is known about prescribing long-term opioids, suggested Dr. Chou, of Oregon Health and Science University, Portland, and lead author of clinical guidelines on chronic opioids for noncancer pain by the American Pain Society and the AAPM.
“We really don't have good quality, long-term data on this, which is scary because we're prescribing these medications so much,” Dr. Chou said. Over the past 2 decades, “we have been prescribing more, but we're also prescribing higher doses and more Schedule II drugs,” which have a higher potential for abuse.
None of these commentators were associated with the Cochrane review. Dr. Bartoli and Dr. Chou reported no potential conflicts of interest. Dr. Fine has been a speaker for Wyeth and an adviser and consultant for many pharmaceutical companies that manufacture opioids.
The 0.3% rate of addiction reported is 'a little misleading, because it's based on pretty crummy data.'
Source DR. CHOUwww.nejm.org