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.