Implications
The timeline periods identified in this study accord strongly with other studies which have demonstrated three phases of scientific communication relating to opioid dose reduction and multidisciplinary care17and even mass media coverage of the opioid crisis.44The former study specifically identified a cross-correlation with a two-year lag between opioid overdose deaths in the US and scientific communication about opioids, clearly identifying a two-way, push-pull relationship between clinical science and the opioid crisis, a major sociohistorical phenomenon. These studies have collectively identified the 2004 moment as a major inflection point in perceptions and activity relating to opioid-related harms, but at the same time have identified that this inflection is tied directly to shifting norms and forces building over the preceding two decades.
Besides communicating outcomes of a series of cases related to opioid prescribing, Foley and Portenoy’s article also included substantive clinical guidance for opioid prescribing for non-cancer pain. By contemporary standards of evidence-based medicine, this guidance can certainly be criticized regarding both the quality of the underlying evidence but also on the opaque and likely idiosyncratic process through which this guidance was developed. Yet, in the specifics of its content, this guidance very much accords with contemporary clinical practice guidelines for opioid prescribing, most of which were developed as responses to overprescribing and its attendant harms.11,12We see here the dual possibilities outlined by Timmermans and Berg45 of similar clinical guidance being used to stake out new professional territory and expand medical autonomy in the period of expansion in the mid-1980s versus holding physicians accountable for their practices during our contemporary period of reassessment (2004-2019). Rather than attending to guidance content alone or even the processes of developing guidance,46this concordance draws our attention back to the importance of sociohistorical context in determining how clinical guidance is interpreted and utilized within health systems, and thus influencing the ultimate impacts of this guidance. As the challenges with the implementation of contemporary guidelines have emphasized,47,48understanding and accounting for this contextual effect is a major challenge for future clinical practice guidance in the complex area of opioid prescribing. Indeed, a plurality of scientific approaches and perspectives are needed to provide appropriate, context-sensitive guidance for clinicians and policy-makers.49–51These are particularly relevant in this therapeutic area of opioid prescribing where processes for developing revised clinical practice guidelines are currently underway.52