Long-Term Pain Therapy With Opioids
JAMA Letter by Dr. Lynn Webster
This article, in a slightly edited form, first appeared online in JAMA on December 18, 2025.
Long-Term Pain Therapy With Opioids
To the Editor The Viewpoint by Drs. Bicket and Bateman highlights the asymmetry between abundant data on opioid-related harms and the scarcity of evidence regarding benefits of long-term opioid therapy for chronic pain. Their analysis is timely and important. Yet an equally critical element is missing from the calculus: the harms of nontreatment.
For people with chronic pain lasting longer than 3 months who have exhausted reasonable alternatives, withholding opioids may not restore safety—it can increase risk. Chronic pain itself is strongly associated with suicidal ideation, attempts, and deaths, independent of depression or substance use. Observational studies of veterans and commercial populations demonstrate that tapering or discontinuing long-term opioid therapy is associated with higher risks of overdose, mental health crises, and suicide, especially when reductions are rapid. These are harms not of opioids themselves but of leaving pain inadequately treated.
Furthermore, patients with high-impact chronic pain have among the lowest scores on validated health-related quality-of-life instruments across chronic diseases, reflecting impairments in sleep, vitality, and social functioning. For many, opioids may not produce dramatic functional gains but can make life more tolerable, reducing suffering that otherwise erodes quality of life.
The US Food and Drug Administration has rightly focused on postmarketing studies of misuse, opioid use disorder, and overdose. However, benefit-risk assessment is incomplete without parallel consideration of nontreatment harms. Regulatory frameworks should explicitly incorporate quality-of-life outcomes, patient-reported outcomes, suicidality measures, and adverse consequences of uncontrolled pain. Without this balance, clinicians are left with only half the information necessary to counsel patients.
The US has learned hard lessons about the dangers of liberal opioid prescribing. It must also acknowledge that indiscriminate restriction carries its own risks. A complete and humane regulatory science requires weighing both sides of the equation.
Lynn R. Webster, MD