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Editor's Note
April 2015

Mitigating the Dangers of Opioids

JAMA Intern Med. 2015;175(4):616. doi:10.1001/jamainternmed.2014.8096

JAMA Internal Medicine has run a series of articles on the dangers of prescription opioids for the treatment of chronic pain.1,2 The best solution is to avoid prescribing opioids for chronic pain because there is no high-quality evidence that they are effective for this indication, and the risk of adverse effects, including death from unintentional overdose, is great.3 But when patients are in pain, and nonopioid methods have proven ineffective, it can be difficult to send patients out of the office without an opioid prescription.

Therefore, it is important to identify strategies to mitigate the dangers of opioids. In that regard, the article by Miller et al,4 is important because it demonstrates that there is less danger to prescribing short-acting rather than long-acting opioids. Among a population of veterans with chronic pain, using pharmacy and administrative data and a propensity score to adjust for baseline differences, the authors found that the risk of unintentional overdose was more than twice as high among patients initiating long-acting vs short-acting prescription opioids. The risk of overdose was more than 5 times higher in the first 2 weeks following initiation of long-acting opioid therapy.

Although it is possible that the higher rate of unintentional overdose among those veterans who received long-acting agents is due to confounding from some unmeasured variable, it would be wise to avoid long-acting agents when initiating opioid therapy for chronic pain. It is also important to avoid high doses of opioids.1 Meanwhile, there is an urgent need for better nonopioid treatments for chronic pain.

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Article Information

Conflict of Interest Disclosures: None reported.

Gwira Baumblatt  JA, Wiedeman  C, Dunn  JR, Schaffner  W, Paulozzi  LJ, Jones  TF.  High-risk use by patients prescribed opioids for pain and its role in overdose deaths.  JAMA Intern Med. 2014;174(5):796-801.PubMedGoogle ScholarCrossref
Gomes  T, Mamdani  MM, Dhalla  IA, Paterson  JM, Juurlink  DN.  Opioid dose and drug-related mortality in patients with nonmalignant pain.  Arch Intern Med. 2011;171(7):686-691.PubMedGoogle ScholarCrossref
Grady  D, Berkowitz  SA, Katz  MH.  Opioids for chronic pain.  Arch Intern Med. 2011;171(16):1426-1427.PubMedGoogle ScholarCrossref
Miller  M, Barber  CW, Leatherman  S,  et al.  Prescription opioid duration of action and the risk of unintentional overdose among patients receiving opioid therapy [published online February 16, 2015].  JAMA Intern Med. doi:10.1001/jamainternmed.2014.8071.Google Scholar