Drs. Streltzer and Johansen Reply

To the Editor: In our article, we cited current evidence that chronic opioid treatment, particularly in high doses, is associated with adverse physiological and psychological consequences. Drs. Fishbain and Gallagher cite recent articles that they believe refute our thesis. We do not feel that this is the case.

Multidisciplinary pain clinics did not report that they were formed to prevent addiction, to our knowledge. Rather, the early clinics postulated that behavioral issues contributed to chronic pain complaints, which often seemed out of proportion to medical pathology. By not rewarding these complaints, either socially or with medication, they reported many treatment successes (1, 2) .

The reference cited (Lusher et al.) does not describe cases of pseudoaddiction, but rather cases “at risk of pseudoaddiction.” The cases selected were not opioid pain medication-seeking chronic pain patients, but rather patients undertreated for acute sickle-cell pain. The article’s introduction and discussion reveals how problematic the concept of pseudoaddiction is.

The articles by Eisenberg et al., Furlan et al., and Devulder et al. review studies of opioid treatment for chronic pain. They reveal that the studies have been of short-term treatment, mostly funded by pharmaceutical companies, and the magnitude of pain relief, when present, was often small and of questionable clinical meaningfulness. Subjects in the trials may not be representative of the broader chronic pain population seen in clinical practice. They conclude that adequately designed trials have not been done and long-term studies are needed.

In a recent, detailed review of the pertinent literature, Clark et al. (3) conclude that “there remains no well-controlled, empirically sound evidence supporting the long-term effectiveness of opioid therapy for chronic noncancer pain.”

In summary, reasonably well-designed studies of opioid treatment of chronic pain are almost all short-term treatment studies, usually using relatively low doses of opioids. We believe the current state of the evidence is as described by Ballantyne and Mao (4), that long-term, high-dose opioids for chronic pain have not been shown to be safe or effective. The case we presented details many of the problems associated with long-term prescription opioid intake.