To the Editor In their Special Report (July 27 issue),1 Volkow and Collins address the opioid epidemic — a major public health crisis of our times. We are delighted to see the National Institute on Drug Abuse (NIDA) and the National Institutes of Health (NIH) address this crisis. For the treatment of chronic pain, the authors suggest opioid formulations with abuse-deterrent properties. However, some foundational data may be lacking. We are not aware of any randomized, controlled trial that has shown that opioids are helpful in controlling chronic pain. The authors also state, “There is strong evidence of the efficacy of cannabinoids, including tetrahydrocannabinol (THC), in treating pain.” We are very (pleasantly) surprised, since this is one of the strongest statements we have seen from the NIDA or NIH in support of the potential benefits of marijuana (cannabinoids) for pain management. Indeed, marijuana has been used for pain control for millennia2; its vilification represents a relatively recent political act. Finally, we believe that there is an appreciable role for nonpharmacologic therapies,3 often marginalized by the medical community, in control of chronic pain. These therapies warrant rigorous investigation and may play a major role in the “all hands on deck” approach wisely supported by the authors. Manish Joshi, M.D.

Thaddeus Bartter, M.D.

Anita Joshi, B.D.S., M.P.H.

University of Arkansas for Medical Sciences, Little Rock, AR

[email protected] No potential conflict of interest relevant to this letter was reported. 3 References 1. Volkow ND, Collins FS. The role of science in addressing the opioid crisis. N Engl J Med 2017;377:391-394 2. Joshi M, Joshi A, Bartter T. Marijuana and lung diseases. Curr Opin Pulm Med 2014;20:173-179 3. Stanos SP, McLean J, Rader L. Physical medicine rehabilitation approach to pain. Med Clin North Am 2007;91:57-95

To the Editor We concur with Volkow and Collins that opioid misuse is a major problem for which innovative solutions are urgently needed. The authors acknowledge the role of nonpharmacologic therapies as an alternative in patients with chronic pain but limit their scope to biomedical methods such as brain stimulation and gene therapy. This focus overlooks a more practical approach that has already been proven to work: deprescribing opioids and other classes of analgesic agents and replacing them with self-management strategies for pain control.1 Chronic pain is multifactorial in nature, with the effects of psychological and social factors often exceeding those of any biomedical factors. A recent systematic review showed that self-management programs are effective in reducing pain and improving function and mood,2 and our own data have shown that self-management strategies (goal setting, activity pacing, stretching exercises, and reducing unhelpful thoughts and behaviors) can facilitate deprescribing. At the initial assessment in our pain-management program, 60% of the patients were taking opioids. By the end of the program, the percentage was down to 10%, and that rate was maintained at 12 months of follow-up.3 Paul A. Glare, M.B., B.S., F.R.A.C.P.

Michael K. Nicholas, Ph.D.

Fiona M. Blyth, Ph.D., F.A.F.P.H.M.

University of Sydney, Sydney, NSW, Australia

[email protected] No potential conflict of interest relevant to this letter was reported. 3 References 1. Nicholas MK, Blyth FM. Are self-management strategies effective in chronic pain treatment? Pain Manag 2016;6:75-88 2. Kamper SJ, Apeldoorn AT, Chiarotto A, et al. Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis. BMJ 2015;350:h444-h444 3. Nicholas MK, Asghari A, Sharpe L, et al. Cognitive exposure versus avoidance in patients with chronic pain: adherence matters. Eur J Pain 2014;18:424-437