Chronic opioid therapy for chronic noncancer pain: How can the scales predict outcome without a good SMACK?

Chronic opioid therapy presents potential benefits to the patient with chronic noncancer pain. Clearly, chronic opioid therapy has risks such as misuse, abuse, and diversion. Screening tools have been developed to define patients at risk for, predict, and detect these negative outcomes. Careful study demonstrates that the tools and their application in clinical practice are imperfect and often fail to fulfill their promise. Barriers to their success range from limited psychometric capabilities to the presence of confounding psychiatric comorbidities. However, the essence of poor outcome in the care of patients with chronic noncancer pain is the inexperience of the practitioner with chronic opioid therapy and the lack of a comprehensive approach to case formulation. The care of patients can only reach its full potential if practitioners follow a standardized approach repeatedly with ongoing reflection about why a particular outcome occurred, what they could do differently, and how a coherent evidence-based rationale supports their recommendations. This iterative process will refine clinical practice and produce experts in pain management.