Implications
The timeline periods identified in this study accord strongly with other
studies which have demonstrated three phases of scientific communication
relating to opioid dose reduction and multidisciplinary
care17and even mass media coverage of the opioid
crisis.44The former study specifically identified a cross-correlation with a
two-year lag between opioid overdose deaths in the US and scientific
communication about opioids, clearly identifying a two-way, push-pull
relationship between clinical science and the opioid crisis, a major
sociohistorical phenomenon. These studies have collectively identified
the 2004 moment as a major inflection point in perceptions and activity
relating to opioid-related harms, but at the same time have identified
that this inflection is tied directly to shifting norms and forces
building over the preceding two decades.
Besides communicating outcomes of a series of cases related to opioid
prescribing, Foley and Portenoy’s article also included substantive
clinical guidance for opioid prescribing for non-cancer pain. By
contemporary standards of evidence-based medicine, this guidance can
certainly be criticized regarding both the quality of the underlying
evidence but also on the opaque and likely idiosyncratic process through
which this guidance was developed. Yet, in the specifics of its content,
this guidance very much accords with contemporary clinical practice
guidelines for opioid prescribing, most of which were developed as
responses to overprescribing and its attendant
harms.11,12We see here the dual possibilities outlined by Timmermans and
Berg45 of
similar clinical guidance being used to stake out new professional
territory and expand medical autonomy in the period of expansion in the
mid-1980s versus holding physicians accountable for their practices
during our contemporary period of reassessment (2004-2019). Rather than
attending to guidance content alone or even the processes of developing
guidance,46this concordance draws our attention back to the importance of
sociohistorical context in determining how clinical guidance is
interpreted and utilized within health systems, and thus influencing the
ultimate impacts of this guidance. As the challenges with the
implementation of contemporary guidelines have
emphasized,47,48understanding and accounting for this contextual effect is a major
challenge for future clinical practice guidance in the complex area of
opioid prescribing. Indeed, a plurality of scientific approaches and
perspectives are needed to provide appropriate, context-sensitive
guidance for clinicians and
policy-makers.49–51These are particularly relevant in this therapeutic area of opioid
prescribing where processes for developing revised clinical practice
guidelines are currently
underway.52