title: Opioid therapy for chronic pain in the United States: promises and perils.
abstract: Opioid therapy offers the promise of reducing the burden of chronic pain in not just individual patients, but among the broad population of patients with chronic pain. Randomized trials have demonstrated that opioid therapy for up to 12-16weeks is superior to placebo, but have not addressed longer-term use. In the United States, opioid sales have quadrupled during 2000-2010, with parallel increases in opioid accidental overdose deaths and substance abuse admissions. Clinical use of long-term opioid therapy is characterized by a pattern of adverse selection, where high-risk patients are prescribed high-risk opioid regimens. This adverse selection may link these trends in use, abuse, and overdose. Long-term opioid therapy appears to be associated with iatrogenic harm to the patients who receive the prescriptions and to the general population. The United States has, in effect, conducted an experiment of population-wide treatment of chronic pain with long-term opioid therapy. The population-wide benefits have been hard to demonstrate, but the harms are now well demonstrated.
authors.affiliation: Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA.
authors.forename: Mark D
authors.initials: MD
authors.lastname: Sullivan
authors.forename: Catherine Q
authors.initials: CQ
authors.lastname: Howe
mesh_terms: D000701:Analgesics, Opioid / Q000627:therapeutic use*; D059350:Chronic Pain / Q000175:diagnosis / Q000188:drug therapy* / Q000453:epidemiology*; D019317:Evidence-Based Medicine; D006801:Humans; D009293:Opioid-Related Disorders / Q000401:mortality*; D010147:Pain Measurement / Q000187:drug effects* / Q000706:statistics & numerical data; D015995:Prevalence; D018570:Risk Assessment; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology
chemical_list: D000701:Analgesics, Opioid
keywords: Iatrogenic harm; Long-term opioid therapy; Mental health disorders; Pharmacoepidemiology; Substance use disorders
references.citation: Lancet Oncol. 2012 Feb;13(2):e58-68
references.pmid: 22300860
references.citation: Arch Intern Med. 2010 Sep 13;170(16):1425-32
references.pmid: 20837827
references.citation: Clin J Pain. 2010 Jan;26(1):1-8
references.pmid: 20026946
references.citation: J Pain. 2012 Nov;13(11):1131-8
references.pmid: 23117108
references.citation: Lancet. 2004 Aug 28-Sep 3;364(9436):739-40
references.pmid: 15337386
references.citation: Pharmacol Biochem Behav. 1978 Aug;9(2):213-20
references.pmid: 568801
references.citation: J Pharmacol Exp Ther. 2008 Apr;325(1):313-8
references.pmid: 18203949
references.citation: Arch Intern Med. 2011 Apr 11;171(7):686-91
references.pmid: 21482846
references.citation: Arch Gen Psychiatry. 2011 Dec;68(12):1238-46
references.pmid: 22065255
references.citation: Pain Med. 2010 Jul;11(7):1063-71
references.pmid: 20642732
references.citation: Spine (Phila Pa 1976). 2008 Jan 15;33(2):199-204
references.pmid: 18197107
references.citation: CMAJ. 2006 May 23;174(11):1589-94
references.pmid: 16717269
references.citation: Arch Phys Med Rehabil. 2012 Feb;93(2):268-74
references.pmid: 22289236
references.citation: Pharmacol Biochem Behav. 1982 Apr;16(4):653-9
references.pmid: 6280208
references.citation: Pain Med. 2008 May-Jun;9(4):444-59
references.pmid: 18489635
references.citation: Neuroimage. 2006 Apr 15;30(3):692-9
references.pmid: 16337817
references.citation: Gen Hosp Psychiatry. 2009 Nov-Dec;31(6):564-70
references.pmid: 19892215
references.citation: Arch Intern Med. 2000 Mar 27;160(6):853-60
references.pmid: 10737286
references.citation: Pain. 2008 Aug 31;138(2):440-449
references.pmid: 18547726
references.citation: J Adolesc Health. 2012 Jun;50(6):553-8
references.pmid: 22626480
references.citation: Pain. 1986 May;25(2):171-186
references.pmid: 2873550
references.citation: Pain. 2010 Sep;150(3):390-400
references.pmid: 20334973
references.citation: Clin J Pain. 2010 Nov-Dec;26(9):763-9
references.pmid: 20842015
references.citation: Arch Pediatr Adolesc Med. 2012 Sep 1;166(9):797-802
references.pmid: 22566521
references.citation: Crit Care Med. 2007 Feb;35(2 Suppl):S85-94
references.pmid: 17242609
references.citation: J Pain Symptom Manage. 2001 Mar;21(3):227-37
references.pmid: 11239742
references.citation: J Am Board Fam Med. 2008 Mar-Apr;21(2):108-17
references.pmid: 18343858
references.citation: Peptides. 2012 Dec;38(2):463-522
references.pmid: 23041439
references.citation: Pain. 2009 Oct;145(3):287-293
references.pmid: 19581051
references.citation: J Pain Palliat Care Pharmacother. 2011;25(1):29-31
references.pmid: 21426215
references.citation: J Pain. 2012 Mar;13(3):266-75
references.pmid: 22285611
references.citation: Clin J Pain. 2014 Jul;30(7):557-64
references.pmid: 24281273
references.citation: J Pain. 2009 Feb;10(2):113-30
references.pmid: 19187889
references.citation: JAMA. 2012 May 9;307(18):1934-40
references.pmid: 22546608
references.citation: Pain Med. 2008 Nov;9(8):1098-106
references.pmid: 18721174
references.citation: Pain. 2010 Dec;151(3):625-632
references.pmid: 20801580
references.citation: BMC Health Serv Res. 2005 Jan 13;5(1):3
references.pmid: 15649331
references.citation: Clin J Pain. 2009 Nov-Dec;25(9):743-51
references.pmid: 19851153
references.citation: Ann Intern Med. 2010 Jan 19;152(2):85-92
references.pmid: 20083827
references.citation: Am J Phys Med Rehabil. 2009 Dec;88(12):995-1001
references.pmid: 19789432
references.citation: Arch Intern Med. 2008 Feb 11;168(3):262-3
references.pmid: 18268165
references.citation: Ann Intern Med. 2007 Jan 16;146(2):116-27
references.pmid: 17227935
references.citation: J Gen Intern Med. 2011 Dec;26(12):1450-7
references.pmid: 21751058
references.citation: JAMA. 2011 Apr 6;305(13):1315-21
references.pmid: 21467284
references.citation: J Pain. 2010 Jul;11(7):602-11
references.pmid: 20444651
references.citation: N Engl J Med. 1989 Mar 30;320(13):844-9
references.pmid: 2604764
references.citation: Clin J Pain. 2008 Jul-Aug;24(6):469-78
references.pmid: 18574357
references.citation: Pain Physician. 2011 Mar-Apr;14(2):91-121
references.pmid: 21412367
references.citation: Cochrane Database Syst Rev. 2010 Jan 20;(1):CD006605
references.pmid: 20091598
references.citation: Clin J Pain. 2014 Feb;30(2):93-101
references.pmid: 23535150
references.citation: N Engl J Med. 1980 Jan 10;302(2):123
references.pmid: 7350425
references.citation: JAMA. 2012 Mar 7;307(9):940-7
references.pmid: 22396516
references.citation: Pain. 2009 Apr;142(3):194-201
references.pmid: 19181448
references.citation: Clin J Pain. 1997 Mar;13(1):6-8
references.pmid: 9084947
references.citation: Drug Alcohol Depend. 2010 Nov 1;112(1-2):90-8
references.pmid: 20634006
references.citation: J Pain. 2005 Jan;6(1):2-9
references.pmid: 15629412
references.citation: Am J Ind Med. 2012 Apr;55(4):325-31
references.pmid: 22213274
references.citation: Nat Rev Neurosci. 2012 May 03;13(6):421-34
references.pmid: 22551663
references.citation: Pain Med. 2012 Jan;13(1):87-95
references.pmid: 22026451
references.citation: Science. 2004 Jun 25;304(5679):1983-6
references.pmid: 15218152
references.citation: Pain. 2004 Dec;112(3):372-380
references.pmid: 15561393
references.citation: J Pain Symptom Manage. 2010 Aug;40(2):279-89
references.pmid: 20579834
references.citation: Anesth Analg. 2007 Jul;105(1):205-21
references.pmid: 17578977
references.citation: Spine (Phila Pa 1976). 2007 Sep 1;32(19):2127-32
references.pmid: 17762815
references.citation: Pain. 2006 Nov;125(1-2):172-9
references.pmid: 16842922
references.citation: J Psychoactive Drugs. 2012 Jul-Aug;44(3):259-65
references.pmid: 23061326
references.citation: J Pain. 2012 Jan;13(1):64-72
references.pmid: 22208802
references.citation: J Gen Intern Med. 2010 Apr;25(4):310-5
references.pmid: 20049546