To the Editor: I disagree with the global condemnation of the use of chronic high-dosage opiates for treating pain patients expressed by Jon Streltzer, M.D., and Luther Johansen, M.D., in the April 2006 issue of the Journal(1). In their clinical case conference about an addicted woman with a pain syndrome, Drs. Streltzer and Johansen argue that there is too much careless prescribing of opiates by well meaning physicians. They maintain that such careless prescribing is fostered by a cultural belief system in the efficacy of opiates for treating chronic pain, a belief that is unsupported by solid evidence. I feel that this is an oversimplification of a complicated and tragic problem.
In my view, there are two broadly defined populations of patients who come to our attention. One group includes patients with pain and addictive drug-seeking behavior, characterized by the woman discussed by Drs. Streltzer and Johansen, and the other group includes patients who have true nonpsychogenic chronic pain, without an addictive drug-seeking pattern of behavior. The treatment model cited by Drs. Streltzer and Johansen is undoubtedly efficacious for some pain drug-seeking patients but would be ineffective for nondrug-seeking, noncancer patients in true chronic pain. Opiates, of course, do cause CNS changes that may enhance pain sensitivity, but in spite of a paucity of controlled studies, they are generally endorsed by specialists as appropriate treatment for refractory pain (2). Undoubtedly, treatment of chronic noncancer pain with opiates is a problem that requires a rigorous clinical approach, with careful screening for drug-seeking behavior and consideration of alternatives (3). One key element in differentiating between the two patient populations mentioned above is to monitor the patient carefully enough to determine whether opiate treatment improves overall functioning or degrades it. Psychiatrists who frequently see patients for psychotherapy may be in a good position to make a reasonable, albeit fallible, determination about into which population their patients fall.
Contrary to the position taken by Drs. Streltzer and Johansen—that there is a culture of over-prescribing opiates—it is my position that opiates are underprescribed by physicians out of a fear of legal retribution. It would be unfortunate if the opinions expressed by Drs. Streltzer and Johansen encourage psychiatrists to avoid attempting to treat this group of patients who sometimes have no alternatives to opiate treatment.
1.Streltzer J, Johansen L: Prescription drug dependence and evolving beliefs about chronic pain management. Am J Psychiatry 2006; 163: 594–5982.Chou R, Clark E, Helfand M: Comparative efficacy and safety of long-acting oral opioids for chronic non-cancer pain: a systematic review. J Pain Symptom Manage 2003; 26:1026–10483.Fine P, Portenoy RK: Opioid Analgesia. New York: McGraw Hill, 2004