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Comment & Response
August 16, 2016

Prescribing Opioids for Chronic Pain

Author Affiliations
  • 1Department of Psychiatry, Harvard Medical School, Boston, Massachusetts
JAMA. 2016;316(7):774. doi:10.1001/jama.2016.9239

To the Editor The Centers for Disease Control and Prevention (CDC) guideline for prescribing opioids for chronic pain1 is a welcome correction of opioid-prescribing practices that stemmed from inadequate evidence and flawed reviews.2

Although an improvement, the review by Dr Dowell and colleagues1 also had shortcomings. For example, it summarized 3 primary care studies using separate ranges for opioid abuse and dependence and thereby minimized the risk of iatrogenic opioid use disorders from long-term therapy. In the Diagnostic and Statistical Manual of Mental Disorders [fourth edition] (DSM-IV), abuse and dependence are dimensions of opioid use disorder and should have first been combined into opioid use disorder rates. Also, the review combined rates with different time frames from the 3 studies—past-month,3 past-year,4 and lifetime5—that are not comparable. DSM-IV criteria specify that symptoms of opioid use disorders cluster within 12 months, and the disease has cycles of remission and relapse. After patients with preexisting nonmedical opioid use disorders are removed, measurements should incorporate the entire duration of use, not just symptoms in the last month or year. The 1 primary care study5 that approximated correct procedures excluded nonmedical opioid users from the sample and then found a lifetime opioid use disorder rate of 21%.