Authors’ reply: The need for greater opioid pharmacovigilance in COPD

We thank Dr Vozoris for his insightful comments on our paper. The use of opioids for treating pain and the underlying evidence base for this indication was not the scope of our article. Although we agree that the evidence for treatment with opioids for "chronic" musculoskeletal pain is inconsistent or weak, we had insufficient data to determine symptom severity and whether the patients were prescribed opioids for chronic or acute pain. It should also be considered that the cited Cochrane reviews on opioids for chronic pain have weak evidence for their conclusions. The review of long-term effectiveness and safety of opioid therapy for chronic noncancer pain by Noble et al included 25 case series and only 1 randomized controlled trial. The clinician should carefully weigh the risk versus benefit of opioids in pain treatment, especially in the setting of clinical instability and in chronic pain. However, we think that there are many situations where opioids have an important role in treating severe distressing pain, where failure to use opioids might contribute to unnecessary suffering and treatment nihilism.