We thank Dr. Pettiway for his remarks. The intent of our article was to identify common challenges when prescribing opioids for chronic pain and offer tips to the provider struggling with how to do so safely. We hope these comments will offer additional clarity.
First, as general internists who are essentially “self-trained” in the management of chronic pain, we fully acknowledge the importance of practical experience in learning how to prescribe opioids safely and effectively. Dr. Pettiway is correct that a dedicated physician who keeps up with the medical literature, attends relevant continuing medical education courses, and strives to provide deliberate, rational, and evidence-based care to his or her patients can do so effectively. However, the medical literature suggests that medical school training in the management of chronic pain is sparse; one review found that in 2011 only 5 out of 133 US medical schools required coursework on pain management, and only 13 offered it as an elective.1 Many primary care providers do feel unprepared to handle this challenge.
Additionally, Dr. Pettiway raises a good question about where misused prescription opioids originate and whether prescribers are responsible. The data show that the majority of misused prescription opioids are obtained from a family member or friend and not directly from a physician.2,3 However, this supply does generally originate from a prescription. Providers need to educate their patients about the risk for diversion, the need to keep pills safely hidden and locked away, and the importance of safely discarding unused supplies. Responsible prescribers need to anticipate these concerns and educate patients about them.
In summary, we firmly believe that primary care providers are capable of safe, effective, and responsible opioid prescribing and hope that our paper provides additional guidance on how to do so.
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