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Systemic Review of Long-Acting Oral Opioids

Posted: October 2005  
Journal of Pain and Symptom Management
Vol. 28, No. 3, September, 2004
Letters to the Editor
Submitted by: L. Manchikanti, M. Boswell, S. Atluri

We congratulate Chou et al. for an excellent systematic review of the comparative efficacy and safety of oral short-acting and long-acting opioids for chronic non-cancer pain. The results of this systematic review, though politically explosive, are extremely important to clinicians. Chou et al., after reviewing the available literature, found that there was insufficient evidence to support the conclusion that different opioids are associated with different efficacy or safety profiles. Indeed, they were unable to demonstrate that long-acting opioids as a class are more effective or safer than short-acting opioids for chronic non-cancer pain. We find this consistent with our own clinical impression that opioids alone rarely reduce pain and improve the quality of life for our chronic pain patients. This is in contrast to those who advocate the use of high doses of long-acting opioids, hoping for better pain control and improvement in quality of life for their patients with chronic non-cancer pain.

Ballantyne and Mao, in a recent review article, which dovetails with the study by Chou, et al, concluded that "scientific research has led to a better understanding of the actions of opioids. Physicians are in a better position now to control opioid use so that it helps, rather than harms, patients." They also provided guidelines recommending a cautious approach to dose escalation and the discontinuation of opioids if treatment goals are not met. They alluded to the fact that it was previously thought that unlimited dose escalation was at least safe, but evidence now suggests that prolonged, high-dose opioid therapy may be neither safe nor effective.

We should take the observations of Chou and colleagues seriously, and consider expanding our future focus to include studies of functional status, untoward side effects of opioids, and the propensity for drug abuse, addiction and diversion in addition to pain relief. The potential risk for physical side effects and behavioral problems, including abuse, addiction and diversion, make it imperative that physicians make every effort to control indiscriminate prescribing, even when under pressure to maintain or increase the doses of opioids they prescribe.