15 - Opioids in Chronic Nonmalignant Pain

Summary

Introduction

Chronic pain, usually considered to be continuous or episodic pain of at least six months duration, is a common cause of major disability. A recent survey of randomly selected adult Americans estimated that almost one individual in five, or 30 million people, suffers from chronic pain (Jorensen and Lietman, 1994). Given the magnitude of the problem, every approach of potential therapeutic value deserves to be studied in a rigorous manner. Although the place of opioid analgesics in the management of cancer pain is beyond question (Levy, 1996), a systematic approach to the role of opioid analgesics in chronic nonmalignant pain has been hindered by perceived risks of serious adverse events. The traditional view has been that, despite reports of partial pain relief, opioid use will lead to impaired cognition and drugseeking behavior that will ultimately impair quality of life. This view has been reinforced by leading journals, which continue to stigmatize the use of opioid analgesics in the management of chronic nonmalignant pain. For instance, a recent review article in the New England Journal of Medicine on the management of the complications of diabetes mellitus states that, in reference to the treatment of painful neuropathy, “narcotic agents should be avoided because of their high potential for abuse” (Clark and Lee, 1995). Given this mindset, reluctance to use long-term opioid therapy in patients with chronic nonmalignant pain is understandable. However, there is emerging evidence that this view is very much distorted and that in selected patients chronic opioid treatment is appropriate and justified.