To the editor: Opioid analgesics are an important class of medicines used in the management of pain. Despite their established benefit in acute pain, their usefulness in chronic pain has been questioned. ¹ As a group, they bring relief to those with moderate to severe pain, but they also carry inherent risks that, when used in vulnerable populations or when combined with sedative-hypnotics, increase the possibility of serious complications such as opioid-induced pain, addiction, and death.Reference Bachuber, Hennessy and Cunninghan ²

Opioid analgesics are also widely diverted and improperly used, which has contributed to a national epidemic of opioid overdose deaths and opioid addiction. Since 2000, almost half a million Americans have died from opioid-related poisonings, up sixfold since the 1980s.Reference Bachuber, Hennessy and Cunninghan ² There are currently no national-level data for opioid-related mortality in Canada, but collective provincial data suggest that our opioid-related mortality parallels that of our southern neighbour, necessitating an urgent and unprecedented call to action by both countries.Reference Carter and Graham ³

A solution to this ever-growing and tragic public health disaster will require a shift in how opioid analgesics are administered and dispensed and, more importantly, how prescribers balance the inherent harms of these effective but complex drugs with the risk factors that patients bring to the table such as age, previous opioid use disorders, and family history, to mention a few. We need to ensure that the benefits of opioid use outweigh the associated harms, regardless of the pain being managed, and that these risks are clearly discussed with patients prior to their initiation. Our recognition that opioid addiction is a life-threatening complication of opioid use, and not a moral failing of users, is key to developing this viewpoint.

Equally important is our approach to pain and the recognition that not all pain is the same, despite the unquestionable suffering that acute and chronic pain can produce. Both require a non-judgemental and compassionate approach based on evidence and best practice. Continuing to listen to the patient’s pain story, to acknowledge suffering, to examine carefully for any new pathology or progression of a pre-existing disease, to maximize non-opioid and non-pharmacological therapies, to risk stratify for harm if opioids are used, and to manage the risk with the patient and stakeholders will be essential as we move forward.Reference Allen, Jewers and McDonald ⁴