Intended for healthcare professionals


Managing twin crises in chronic pain and prescription opioids

BMJ 2019; 364 doi: (Published 06 March 2019) Cite this as: BMJ 2019;364:l917
  1. Sean Mackey, Redlich professor1,
  2. Ming-Chih Kao, clinical assistant professor1
  1. 1Department of Anesthesiology, Perioperative and Pain Medicine, Division of Pain Medicine, Stanford University School of Medicine, Palo Alto, CA, USA
  1. Correspondence to: S Mackey smackey{at}

National pain strategies are part of the solution

Solutions are urgently needed to the conflicting crises in chronic pain and prescription opioid use in the United States and internationally.123 Roughly 50-100 million Americans are living with ongoing pain at an estimated cost of $635bn (£480bn; €560bn) annually.1 Roughly 20 million live with serious chronic pain that substantially restricts work, social, and self care activities.145 At the same time, over 130 Americans die every day from opioid overdose.6

Long term use of opioids is increasingly associated with harmful side effects, risk of misuse, abuse, and addiction.678 However, stable doses of opioids can provide durable pain relief with limited side effects for a subgroup of people.9 Consequently, a poor risk:benefit ratio overall may obscure a positive profile in some patients with chronic pain. The heterogeneity of chronic pain conditions and a lack of awareness of such variation among clinicians, payers, and the public creates serious tension between opioid aversion in general and the needs of patients who rely on opioid maintenance treatment to enable daily …

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