Author Affiliations: Department of Veterans Affairs, Health Services Research & Development Center of Excellence, Ann Arbor, Michigan (Drs Bohnert and Blow) (email@example.com); Department of Veterans Affairs, Health Services Research & Development Center of Excellence, Indianapolis, Indiana (Dr Bair).
In Reply: We agree with Dr Geller's caution that unilateral application of opioid dose limits would likely result in unnecessary undertreatment of pain but disagree with the characterization of our article as suggesting dose minimization. We avoided recommendations of dose limitations and instead focused on a risk-benefit framework, assessment of substance use, use of urine toxicological screens and other opioid monitoring tools, and frequent follow-up.
Geller additionally notes that timing of opioid dose may play a role in opioid overdose risk because of ventilation reflex suppression during sleep. We agree that patients treated with opioids should be educated on the risk of sleep-disordered breathing and point to recent Veterans Affairs/Department of Defense guidelines1 that recommend clinicians be vigilant for sleep-disordered breathing in patients receiving opioids and consider a sleep study when sleep-disordered breathing is suspected. However, we believe there is insufficient evidence to support restricting the dosing of long-acting opioids to mornings and short-acting opioids to several hours prior to bedtime. Studies specifically designed to determine whether this dosing strategy would reduce opioid overdose risk are needed.
Bohnert ASB, Blow FC, Bair MJ. Opioid Overdose-Related Deaths—Reply. JAMA. 2011;306(4):379-381. doi:10.1001/jama.2011.1039