Opioids for Intractable Pain: The Good, the Bad and the Ugly

Abstract

Pain medicine, in fact all of medicine and society, remains in a quandary about the use of long-term opioid analgesics for intractable pain. In the calculus of Public Health and moral reasoning, does the cost-effectiveness benefit, “the good,” of appropriate access to opioids for relief of pain and suffering and improved quality of life, which the opioids might obtain for many of the 40 million or so adults with chronic or recurrent pain, outweigh costs of the risks of addiction or diversion, “the bad,” that exist for a much smaller percentage of the population? All interest groups weighing in on this question agree that opioids can be used judiciously for individual cases in which other methods have failed, and when the risk of addiction or diversion of opioids is low. However, to find the best way to facilitate appropriate use of opioids for intractable pain while simultaneously reducing risk for diversion and abuse, in the absence of adequate studies and in the face of mixed messages from the Drug Enforcement Agency (DEA), anger, uncertainty, anxiety, and fear, “the ugly,” persist. Thus far, the DEA's efforts through their regulatory and investigatory policies to discourage diversion and abuse have failed to achieve their stated goal of enabling appropriate clinical …