Urgency and Balance Needed in Addressing Opioid Epidemic

The ongoing opioid crisis is at the intersection of 2 substantial public health challenges: improving the treatment of pain and minimizing the harms that can arise from use of opioid medications. Recent Viewpoints in JAMA highlighted this tension. In one article, the authors emphasized that “there is no evidence that opioids are effective in chronic pain conditions and significant evidence that they cause harm,” and urged that they be used only as a “last resort.”1 In another article, the authors expressed dismay that federal policy has “disproportionately focused on reducing opioid use rather than increasing pain relief,” and that “excessive concerns” about opioids could “virtually eliminate” opioids as an option for chronic pain and could even deter physicians from prescribing small amounts for acute pain.2

Pain Management and the Opioid Epidemic,3 a report by a committee of the National Academies of Sciences, Engineering, and Medicine, envisions a path leading to reduced reliance on opioids for chronic pain while counseling against arbitrary regulatory restriction of responsible prescribing for patients whose pain has not been alleviated by alternative treatments. This report updates Relieving Pain in America,4 the 2011 report by the Institute of Medicine, and summarizes the state of the science on the harms associated with opioid misuse and the effects of strategies aiming to reduce those harms. One of the key aims of the current report is to advise the US Food and Drug Administration (FDA), the study sponsor, regarding actions it could undertake “to balance the needs of pain patients and the need to address opioid misuse.”

The committee heard a broad range of views from recognized experts in pain management, opioid misuse, and public health. The report recommends an “all hands on deck” response, including a culture change among prescribers; a proactive approach by the FDA and state regulators regarding opioid approval and prescription monitoring; a commitment to funding basic and translational research to develop nonopioid paradigms for pain management; and better access to treatment for opioid use disorder (OUD) and to medication for preventing overdose deaths. A key message in the committee’s report is that prescription opioids must be viewed by patients, physicians, nurses, and others as part of a larger ecosystem that also encompasses the illicit use and sale of prescribed opioids diverted from the legal market as well as the use and sale of illegally manufactured opioid products, including potent synthetics.