{"doi":"10.1002/cncr.35487","title":"Reply to “Embracing an ethical‐legal framework for balanced opioid prescribing: A reply to Bulls”","abstract":"We thank Dr. Kollas et al. for their thoughtful commentary entitled Embracing an ethical-legal framework for balanced opioid prescribing. We appreciate their review of the judicial system's influence on opioid prescribing and echo their calls for balanced opioid prescribing for people living with pain. Patients with pain of any etiology deserve personalized and compassionate care, and the creation of guiding frameworks is important to direct improvements in pain care. We welcome the opportunity to add comments to this discourse. As the authors note, pain management—especially for patients in cancer remission—is rife with ambiguity. State-level prescribing policies are subject to interpretation by patients, clinicians, health care systems, and law enforcement officials, yet carry the potential for serious consequences.1 Federal and clinical guidelines conflict, legal exemptions in survivorship are vague, public attitudes swing between extremes, and care models are highly fragmented.1, 4 Clinicians are expected to make personalized, complex prescription recommendations despite a legal landscape that does not always account for nuanced decision making. For example, a key consideration in chronic cancer pain management is that many patients begin prescription opioids during active disease (versus patients living with chronic noncancer pain, who may struggle to obtain prescription opioids at all). Thus, for cancer survivors exposed to prescription opioids at high rates, the clinical question is often whether to continue prescribing, rather than to initiate prescribing. For patients with active cancer, opioid prescribing is guideline-concordant and frequently offered.5 For patients with chronic noncancer pain, opioid prescribing is generally discouraged and frequently inaccessible.2 There is no well established approach to align these two conflicting views and their resulting management approaches, yet loss of license, imprisonment, and the potential for violence may be at stake. How are clinicians to feel confident in their prescribing choices and to document them accordingly? Given the findings of our study, in which clinicians asked for better guidance, education, consultation, and support, we assert that clinicians want to make opioid recommendations that are both data-driven and patient-centered. For patients in cancer remission, clinical and research efforts to refine opioid prescribing are arguably more akin to charting new territory than restoring balanced opioid prescribing. Patients with cancer have always suffered from pain associated with their disease and treatments, but novel treatments, improved detection, and early intervention efforts have substantially improved cancer survival rates.6 Increasing numbers of patients now achieve remission, and chronic pain is among the most common long-term symptoms in survivorship.3 Unfortunately, pathophysiology underlying the development and maintenance of chronic cancer pain remains elusive, limiting the development of targeted therapeutics. Patients in remission are also often explicitly excluded from studies of active disease and/or chronic noncancer pain, limiting our ability to fully characterize the risks and benefits of prescription opioids in this population. Without this critical evidence, it is difficult to envision what truly balanced opioid prescribing looks like for cancer survivors with pain. In sum, we support Kollas and colleagues' goal to improve compassionate treatment of severe pain. In service of this goal, we invite future researchers and clinicians to improve understanding of cancer pain in survivorship—where it arises from, why it persists, and how best to offer targeted, tailored, and ethical care—to improve care models for this population. Until then, to prescribe or not to prescribe may always be the question. Dr. Hamm reports an immediate family member with employment at Arcadia Health Solutions. The authors disclosed no other potential conflicts of inte","journal":"Cancer","year":2024,"id":501192,"datarank":0.0,"base_score":0.0,"endowment":0.0,"self_citation_contribution":0.0,"citation_network_contribution":0.0,"self_endowment_contribution":0.0,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":0,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9489,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2024-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":380782,"name":"Megan Hamm","orcid":"0000-0002-7842-5290","position":1,"is_corresponding":false},{"id":1152579,"name":"Julia Wasilewski","orcid":null,"position":2,"is_corresponding":false},{"id":1086037,"name":"Donna Olejniczak","orcid":null,"position":3,"is_corresponding":false},{"id":409163,"name":"Sarah Bell","orcid":"0000-0002-9455-5108","position":4,"is_corresponding":false},{"id":503280,"name":"Jane M. Liebschutz","orcid":"0000-0003-3492-1521","position":5,"is_corresponding":false},{"id":691075,"name":"Hailey W. Bulls","orcid":"0000-0003-1005-0303","position":0,"is_corresponding":true}],"reference_count":5,"raw_metadata":null,"created_at":"2026-07-19T02:10:12.068207Z","pmid":"39031609","pmcid":null,"fwci":null,"citation_percentile":null,"influential_citations":0,"oa_status":null,"license":null,"views":0,"total_file_size_bytes":0,"version_count":0,"fair_f":null,"fair_a":null,"fair_i":null,"fair_r":null,"fair_zscore":null,"fair_rationale":null,"fair_model":null,"fair_agent_version":null,"fair_fulltext_source":null,"fair_has_llm":null,"fair_computed_at":null,"clinical_trials":[],"software_tools":[],"db_accessions":[],"linked_datasets":[],"topics":[]}