Editor, – The article by Michael McDonough (Aust Prescr 2012;35:20-4) was well written and includes some good material. However, I consider many statements to be incorrect and dangerous such as:
- ‘Every prescription for opioids is fraught with danger’
- ‘Before prescribing long-term therapy, there should be a trial period of one month’. By that time many people are already dependent.
- ‘If prescribing beyond 12 months a second opinion should be obtained’. This person is dependent.
Donald Beard
Surgeon
Norwood, SA
Michael McDonough, author of the article, comments:
While I find myself agreeing with many of the sentiments expressed in the letter, there is no evidence to support the broader generalisation that after a month or even 12 months many patients are already dependent. However, there is some evidence to support that at least some patients may benefit from extended opioid therapy.1 Dr Beard is referring to the state of physiological dependence rather than the dependence syndrome as described in DSM IV-TR2 which is synonymous with the term addiction.
Most people who develop a form of physiological dependence to opioids in the context of medical treatment can be withdrawn from opioids without significant risk of developing persistent craving for opioids or chronic, relapsing and remitting opioid use disorder. Further, there are patients who may derive benefit from continued opioid therapy but within the caveats that both I and others have described.3
Having concern about opioid use is always appropriate. However, this concern should not, of itself, justify the absolute avoidance approach, especially in appropriately selected and monitored patients.
