Common Adverse Effects and Complications of Long-Term Opioid Therapy

This Supplement to Pain Medicine emerges from the editors' and authors' longstanding commitment to the primary axiom of Medicine: first do no harm (nonmaleficence). There is no question that opioids can and do have serious adverse effects, even when used correctly and for justifiable reasons. For that purpose alone, it is important to review the exigent literature on the effects of long-term opioid use and critically analyze outcomes in order to provide clarity and guidance for practitioners who care for patients with debilitating pain conditions.

The burgeoning rate of prescription opioid misuse, abuse and opioid related mortality and morbidity has fueled considerable debate over the last several years, arguing the benefits and harms of long-term opioid therapy, with strongly voiced “pro versus con” opinions and sentiments. And it may turn out that this Supplement helps to inform responsible deliberation—and even public policy– around this controversial approach to pain care. But our purpose is far more clinically pragmatic than adding fuel to this dialectic. Its intent is to assist every patient burdened with persistent pain to live the healthiest life they can, notwithstanding their underlying medical condition and difficult treatment choices they must make.

Prescribers need up-to-date and reliable information in order to balance therapeutic intent with potential morbidity, regardless of the condition they are treating and for prescribers to utilize this information to provide patients with accurate informed consent when initiating opioid therapy. Although this Supplement focuses on what can go wrong with opioids, it is not our intent to suggest that possible adverse effects outweigh putative benefits. This can only be determined on a case-by-case basis, applying sound principles of practice during all phases of care: assessment, initiation of treatment, titration, and ongoing monitoring and evaluation of outcomes. Anticipating, preventing and avoiding medical harms must always be balanced against the obligation of all healthcare professionals to relieve the burdens of illness, disease and injury. In ethical terms, this means contextually balancing the dual (and oftentimes competing) principles of non-maleficence and beneficence.

Context is created through an understanding of the behavioral, medical, pharmacological, social, functional and even financial circumstances of each patient under consideration for long-term pain treatment. The consequences of treating with opioids (or continuing opioid therapy) must always be considered against the consequences of not treating with opioids (or discontinuing opioid therapy)–an issue of proportionality that is rarely elucidated in the typically polarized (and polarizing) arguments for or against continuing to have opioids available as a treatment option in the chronic pain care armamentarium.

In light of the authors' efforts, within the framework of these introductory comments, we hope this Supplement meets its intended purpose: helping you, the committed clinician, to serve your patients' needs as effectively as possible.

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