Abstract
While the role of opioid analgesics has been established in the treatment of cancer pain, reservations persist about appropriate use in patients with chronic noncancer pain. Recent evidence from controlled clinical trials supports the effectiveness of opioids for treating noncancer pain of varying etiologies. The safety of opioids in noncancer patients has been an area of controversy because of confusion between physical dependence, which develops in all patients receiving opioids chronically, and addiction, which is a behavioural diagnosis that is rarely made in patients appropriately treated with opioids for pain. Abuse by secondary recipients of opioids is well documented and arises as a result of diversion by primary recipients, double-doctoring, forgery and theft. The frequency of forgery and theft of different opioids appears to be largely related to the corresponding number of legitimate prescriptions. While it is legitimate medical practice to prescribe opioid analgesics to patients with chronic noncancer pain, there is clear evidence that prescribing is affected by concerns of regulatory sanctions. Recent guidelines, including most recently comprehensive guidelines issued by the Canadian Pain Society, should help to reduce inappropriate undertreatment because of such concerns.
Highlights
The purpose of the present review is to summarize the evidence demonstrating the efficacy of opioids, as well as their limitations, in the treatment of noncancer pain, to offer a perspective on the many issues surrounding their use for this indication, and to discuss the current extent and potential for abuse of these drugs
CONCERNS OVER REGULATORY SANCTIONS It is a legitimate medical practice to prescribe opioid analgesics to patients provided that the patient record documents the following: the existence of a valid doctor-patient relationship, that the opioid analgesics are prescribed for a recognized therapeutic indication and the details of each prescription
CLINICAL GUIDELINES To address physicians’ concerns, a number of organizations have published guidelines or discussion papers for the appropriate use of opioids in patients with pain of nonmalignant origin. These guidelines support the use of opioid agents in managing chronic pain in patients whose pain is not controlled by alternatives and indicate that addiction, tolerance and toxicity are not believed to be major issues when opioids are used as part of a pain management program
Summary
The purpose of the present review is to summarize the evidence demonstrating the efficacy of opioids, as well as their limitations, in the treatment of noncancer pain, to offer a perspective on the many issues surrounding their use for this indication, and to discuss the current extent and potential for abuse of these drugs. Recent controlled trials using morphine [6], oxycodone [7] and codeine [8,9] have convincingly demonstrated efficacy in terms of reduction of pain scores and/or pain disability indexes, in a variety of musculoskeletal and neuropathic pains. In two short term studies of controlled-release codeine, in patients with chronic arthritic or back pain, significant reductions in pain score relative to placebo [8] or as required dosing of acetaminophen plus codeine [9] were demonstrated at mean doses of 273 mg/day and 200 mg/day, respectively. At mean doses of 159 mg/day codeine or 40 mg/day oxycodone, significant reductions in pain were demonstrated These studies in chronic noncancer pain employed scheduled dosing of controlled-release formulations of opioids, which avoid rapidly fluctuating plasma concentrations and may be less likely to lead to abuse [12].
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