Introduction:
The over-prescribing of opioids for chronic non-cancer pain has played
an important role in the development of the contemporary opioid crises
in high-income North
America.1–3In 2020, there were 6,214 and 81,000 opioid-related deaths in
Canada4and the United
States,5respectively. The combined costs of opioid use disorder and opioid
overdoses in the United States were estimated to total USD 1.021
trillion in 2017
alone.6Historically, physicians had considered opioids to be effective and
important treatments primarily for managing cancer pain. However, by the
mid-1980s, scientific opinion started to shift towards considering the
use of opioids to manage chronic non-cancer
pain.7,8Many have pointed specifically to Portenoy and Foley’s 1986 article,
“Chronic use of opioid analgesics in non-malignant pain: report of 38
cases”, as a seminal study that opened the door to mass opioid
prescribing.2,3,9
Portenoy and Foley’s retrospective observational study of 38 patients
fitting the criteria of having “non-malignant pain syndromes treated
with opioid analgesics for at least 6 months” reported that only two
patients - both with histories of substance abuse or mental illness -
experienced management problems. They therefore concluded that opioids
could be “an alternative therapy which may be more humane and provide
greater benefit at lesser risk than other approaches” for the treatment
of chronic non-cancer pain.
While advocating for opioid prescribing to treat chronic pain, the 1986
study also presented opioid prescribing guidance. This included the
tenet that “opioid maintenance therapy should be considered only after
all reasonable attempts at pain management have
failed.”10In many ways, the specifics of this guidance are similar to recent
national guidelines published nearly four decades later in the United
States11and
Canada.12Even though the processes for producing these guidelines differed, they
arrived at similar conclusions regarding prescribing opioids as a last
resort, conducting risk-benefit analyses prior to prescribing,
considering the importance of multidisciplinary care, and limiting
doses.
Contemporary guidelines were developed as major clinical and policy
responses to mass harms from opioids, while Portenoy and Foley’s
guidance, despite its concordance with contemporary guidance, has been
criticized as having initiated these very harms. This disconnect makes
us reconsider the contemporary framing of the Portenoy and Foley article
and raises important questions about how this paper has been cited,
used, and interpreted over time.
Our primary objectives for this study were to explore the following
questions:
What was the nature and magnitude of the impact of Portenoy and
Foley’s 1986 article on the subsequent scientific literature?
How were Portenoy and Foley’s 1986 findings promoted, rejected, and
constructed by the medical and scientific communities over time? What
does this tell us about the evolution of pain and opioid prescribing
research and practice?
This will provide insight not only into historical driving forces of the
contemporary opioid crises, but also into historical and contemporary
currents in clinical epidemiology and clinical medicine, including where
the two are supposed to meet — in the realm of evidence-based
practice.