{"doi":"10.1093/fampra/cmad002","title":"Prioritizing patient values for chronic pain care: a path out of the pain reduction regime?","abstract":"Recently, the Centers for Disease Control and Prevention (CDC) updated their Clinical Practice Guideline for Prescribing Opioids for Pain.1 Although the guidelines focus on prescribing opioids for pain, the initial recommendations strongly encourage providers to prescribe nonpharmacologic and nonopioid medications in lieu of opioids. Recommendation 1 begins: “Nonopioid therapies are at least as effective as opioids for many types of acute pain.” Recommendation 2 begins: “Nonopioid therapies are preferred for subacute and chronic pain.” These recommendations echo other guidelines. The first recommendation of the 2022 Veterans Administration (VA) Opioid Guidelines begins: “We recommend against the initiation of opioid therapy for the management of chronic non-cancer pain.”2 The American College of Physicians (ACP) guideline on low back pain recommends nonopioid and nonpharmacological treatments3 and the United Kingdom’s National Institute for Health and Care Excellence (NICE) instructs providers to not initiate opioids as part of chronic pain treatment and to wean when there is a lack of evidence of benefit.4 Nevertheless, opioid treatment of chronic pain remains common. In 2020, 43.3 prescriptions were written per 100 US residents, a total of more than 142 million opioid prescriptions.5 While the United States has the highest level of opioid prescription rates in the world, and consequently the highest level of opioid-related problems, there is evidence of continued elevated opioid prescription and related problems in many developed countries.6 Why do opioids remain a common treatment for chronic pain requested by many patients despite a limited evidence base, recommendations against their use, and established risk of harm? One reason is that opioids offer a swift means of reducing pain, as pain reduction begins soon after ingestion of the first dose. Opioid tolerance and dependence develop gradually and may not be apparent to patients taking opioids, nor will increases in symptoms of withdrawal between doses which may be mistaken for worsening of the original pain problem.7 Second, patients with chronic pain may assert that they have a right to pain relief.8 They may ask clinicians: “Don’t you believe I have pain? Don’t you believe that I deserve relief?” Finally, patients and clinicians often believe that pain reduction is a necessary first step in the chronic pain treatment process. They believe that only after pain reduction is achieved can life improve. However, recent research suggests this is not true: during chronic pain treatment, reductions in pain more often follow than precede improvements in function, mood, and sleep.9 Pain reduction is also prioritized in chronic pain care because this goal is given ethical authority as a preeminently patient-centred goal. Pain is important to patients. It is aversive, impairs quality of life, and is one of the most important causes of disability for the global population.10 Clinicians seek pain reduction out of respect for their patients as suffering humans. We refer to these experiences and beliefs about the role of pain reduction in chronic pain care as the “pain reduction regime.” We believe that many primary care clinicians feel trapped in this regime and compelled to prescribe opioids to achieve pain reduction.11 Denying patients access to analgesics which may produce pain reduction feels like denying them access to a quality life. A major problem with recent pain management guidelines (e.g. CDC, ACP, VA, and NICE) is that they do not specify practical and actionable ways out of the pain reduction regime that are appropriate for chronic pain care. Primary care providers need a goal for chronic pain care that is more patient-centred and evidence-based than pain reduction through analgesics. The problem is that these patient-centred goals vary from patient to patient and are difficult to assess and target in clinical care. To achieve outcomes beyond pain reduction that are mea","journal":"Family Practice","year":2023,"id":354625,"datarank":0.29188652235829704,"base_score":1.9459101490553132,"endowment":1.9459101490553132,"self_citation_contribution":0.29188652235829704,"citation_network_contribution":0.0,"self_endowment_contribution":0.29188652235829704,"citer_contribution":0.0,"corpus_percentile":null,"corpus_rank":null,"citation_count":6,"citer_count":0,"citers_with_citation_signal":0,"citers_with_endowment":0,"datacite_reuse_total":0,"is_dataset":false,"is_dataset_confidence":0.9569,"is_data_producer":false,"deposit_databanks":null,"is_oa":true,"file_count":0,"downloads":0,"has_version_chain":false,"published_date":"2023-01-01","fair_score":null,"fair_percentile":null,"algorithm_id":"datarank_citation_only_1hop_v6","ranking_scope":"data_only","authors":[{"id":418545,"name":"Kevin E. Vowles","orcid":"0000-0003-4255-9067","position":1,"is_corresponding":false},{"id":1000001,"name":"Elisabeth B. Powelson","orcid":"0000-0002-7782-3078","position":2,"is_corresponding":false},{"id":250035,"name":"Kushang V. Patel","orcid":"0000-0002-8443-2876","position":3,"is_corresponding":false},{"id":704726,"name":"M. Carrington Reid","orcid":"0000-0001-8117-662X","position":4,"is_corresponding":false},{"id":259941,"name":"Mark D. Sullivan","orcid":"0000-0002-4396-6038","position":0,"is_corresponding":true}],"reference_count":26,"raw_metadata":{"citation_network_status":"fetched"},"created_at":"2026-07-19T01:13:11.976628Z","pmid":"36656068","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":[]}