Response to Baca

To the Editor:—We appreciate the opportunity to respond to the letter by Baca et al.

While our figure did show that the intervention group more often reported that they were “more likely to prescribe opioids” after the training (intervention 30% vs control 10%), this occurred in a minority of both groups, was not a statistically significant difference, and was not the intended purpose of the training. The training was intended to improve the quality of opioid care when deemed clinically appropriate. It did not address the appropriateness of opioid use (other than to discourage it in the presence of substance abuse), because this is a highly controversial area of practice with a rapidly evolving database.

Long clinical tradition and a substantial research literature supports our assertion that methadone is “the long-acting opioid least prone to abuse.”¹ Increased rates of opioid-related deaths in recent years have been reported in various states, including our own.² These have occurred as prescription opioid availability has increased. Abuse of opioids has generally increased, but abuse is most prevalent with Oxycontin and hydrocodone, not methadone.³ There may be special problems with methadone safety due to the need for complicated dose conversion from other opioids and due to the fact that patients may not understand that “as needed” dosing is not safe or effective with methadone.⁴

We agree that the efficacy and safety of long-term opioid therapy for chronic pain remains to be demonstrated, especially for the psychiatrically vulnerable patients who are likely to receive long-term opioids in clinical practice. We have recently shown using population-based data that patients with psychiatric disorders are significantly more likely to receive opioids for chronic pain.⁵ While it is likely not permissible to deny opioid treatment to all patients with chronic nonmalignant pain, more research is clearly necessary to define when and how to use opioids to maximize benefit for patients with this pain.