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Show us the evidence: a reply to Bartleson's article.

We are grateful for the chance to respond to Dr. Bartleson's review on the use of opioid analgesics for nonmalignant low back pain. He concludes that opioid analgesics have a place in the treatment of persons with low back pain while also highlighting the shortcomings in the literature and lack of properly controlled clinical trials. Our comments are intended to further identify what we know now and where the research needs to go.

Anyone involved in the treatment of persons with chronic pain over the past two decades will have recognized the dramatic change in the clinical use of opioids for chronic noncancer back pain. In the early 1980s few advocated prescribing opioids for chronic nonmalignant pain because of the fear that everyone started on this type of therapy would become addicted. A dramatic change in opioid prescribing practices came, in part, by the championing literature of Joranson [1], Portenoy [2], and others who argued, based on their experience with cancer pain patients, that opioids can be effectively and safely managed. At that time, there was little empirical support for this practice, but there was much encouragement to help stop the “needless tragedy of pain”[3]. Unfortunately, the empirical support for chronic opioid therapy remains limited today. The results of our study [4] and others demonstrated that opioid therapy for chronic back pain can be used without significant risk of abuse, and individuals can be compliant …