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Letter to the editor regarding sullivan et al.

To the Editor:—In their brief report “Training Internists in Shared Decision Making About Chronic Opioid Treatment for NonCancer Pain,” Sullivan, Leigh, and Gaster reported on their training of Internal Medicine physicians (principally residents) in the prescribing of opioids, especially methadone, to patients with chronic noncancer pain.1 They reported that their training resulted in “improvement,” with physicians in the intervention group being 3 times more likely to prescribe opioids at 3 months posttraining than those in the control group. 
 
The authors chose methadone “as the long-acting opioid least prone to abuse.” Although it is debatable if methadone is actually the opioid least prone to abuse, what is certain is that methadone is causing many preventable deaths. A National Assessment by the Center for Substance Abuse Treatment of the Substance Abuse and Mental Health Services Administration concluded that dramatically increasing methadone-associated mortality is from its use as an analgesic, not from its use in opioid addiction treatment.2 In the most recent data from the Centers for Disease Control published on January 31, 2006, methadone was implicated in 2,376 deaths and other specified opioids were implicated in an additional 4,484 deaths (not including 2,101 deaths from heroin) in 2002 in the United States.3 
 
In their reference to the editorial by Van Korff and Deyo,4 the authors acknowledged the belief by many that the efficacy of long-term opioid treatment of chronic nonmalignant pain remains unproven. The authors failed to mention the unacceptably high mortality that is resulting from this questionable practice. We should be training our residents in safe and effective treatments for chronic nonmalignant pain, not in those that are of questionable efficacy and are causing great harm.