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Professor & Holder of Margaret Milam McDermott Distinguished Chair; Department of Anesthesiology and Pain Management; University of Texas Southwestern Medical Center at Dallas; Dallas, Texas; paul.white{at}utsouthwestern.edu (White) Professor of Surgery; Section for Surgical Pathophysiology; The Juliane Marie Centre, Rigshospitalet; Copenhagen, Denmark (Kehlet)
In Response:
We are pleased that Brennan et al. (1) agree with our recommendation regarding a "balanced approach to pain management" which relies on non-opioid analgesics to minimize the need for narcotic analgesics (2). Our primary criticisms of their review article (3) were related to both their failure to provide rigorous scientific evidence that healthcare providers fail to provide adequate pain relief for patients because of a lack of concern and/or misconceptions regarding the use of analgesics, as well as their statement that the "under treatment with opioids is a major factor contributing to pain and suffering."
Our editorial (2) primarily focused on analgesic therapies for acute pain management. The article by Sykes (4), mentioned by Brennan et al. (1) comments that, despite a 10-fold increase in global morphine consumption over the last 20 years, inadequate pain control remains a problem throughout the world. Perhaps a more important contributing factor than the under-utilization of opioids or lack of patient access to these compounds is the inappropriate use of opioid analgesics in the management of acute and chronic pain (5,6).
As documented in our editorial (2), the recent emphasis on pain as a fifth vital sign and the resultant increased utilization of opioid analgesics (in an effort to reduce pain scores below an arbitrarily chosen value), has contributed to a significant increase in opioid-related morbidity. As suggested by Kozol and Voytovich (7), the misinterpretation of the "fifth vital sign" has been a major contributing factor to this increase in opioid-related complications in the postoperative period. We would agree with Livingston (8) that the concept of pain as a fifth vital sign should be critically re-evaluated.
We recognize that despite their many undesirable side effects, opioid analgesics are beneficial in clinical situations where non-opioid analgesic technique fail to provide adequate pain relief (6). However, we would encourage our academic colleagues (1,3) and organizations like WHO (9) to provide scientific evidence to support claims that liberalizing policies on opioid use will "significantly and readily alleviate human suffering." In all other respects, we would agree with the shared conclusions of Brennan et al. (1,3) and Scholten et al. (9).
REFERENCES
This article has been cited by other articles:
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  J. M. Feldman Consumer Reports for Anesthesia Equipment: An Idea Whose Time Has Come? Anesth. Analg., December 1, 2007; 105(6): 1867 - 1867. [Full Text] [PDF]
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