Opioids for Chronic Nonterminal Pain
Opioids for Chronic Nonterminal Pain
There is no doubt that the association of opioid use with addiction produces many conflicts with regard to opioid treatment of pain. When it became necessary to introduce drug regulations because the availability, use and abuse of opioids and other addictive drugs had reached unacceptable levels, this compounded the problem, adding a host of legal considerations to the existing moral and ethical dilemmas inherent in balancing humane care with protection from addiction. After the introduction of regulations, it took many years to reestablish opioid treatment as necessary and proper for the control of acute and terminal cancer pain. In fact, as opioid use was reestablished for these indications, it became clear that problematic addiction virtually never arose during the treatment of severe, acute and cancer pain. But long-term outpatient opioid treatment is likely to be associated with higher risk. Indeed, despite the somewhat optimistic picture painted by early reports such as the seminal report by Portenoy and Foley estimating addiction risk during chronic opioid treatment at approximately 5%,25 higher estimates of up to 19% (this being the upper limit of addiction rates found in a systematic review by Fishbain et al), are now accepted by the medical community. There is a problem, however, with all estimates of addiction risk, and that is that iatrogenic opioid addiction (addiction arising during opioid treatment of pain), is poorly defined and understood, despite years of effort to clarify its terminology and processes. It seems that iatrogenic opioid addiction is simply what the reporting person says it is, and that the vast range of published estimates of risk reflects the lack of an agreed definition. Portenoy and Foley understood at the outset that problematic addiction is unlikely to arise when treatment is provided in a controlled, careful and supportive setting. As they said: It must be recognized that the efficacy of this therapy and its successful management may relate as much to the quality of the personal relationship between physician and patient as to the characteristics of the patient, drug, or dosing regime. As is the case with opioid maintenance for opioid addiction, a careful structured maintenance regimen is the best course for preventing the emergence of problematic opioid-seeking behaviors. It follows that observed addiction rates are likely to be higher when practice deviates from the careful controlled approach recommended in published guidelines.
Addiction
There is no doubt that the association of opioid use with addiction produces many conflicts with regard to opioid treatment of pain. When it became necessary to introduce drug regulations because the availability, use and abuse of opioids and other addictive drugs had reached unacceptable levels, this compounded the problem, adding a host of legal considerations to the existing moral and ethical dilemmas inherent in balancing humane care with protection from addiction. After the introduction of regulations, it took many years to reestablish opioid treatment as necessary and proper for the control of acute and terminal cancer pain. In fact, as opioid use was reestablished for these indications, it became clear that problematic addiction virtually never arose during the treatment of severe, acute and cancer pain. But long-term outpatient opioid treatment is likely to be associated with higher risk. Indeed, despite the somewhat optimistic picture painted by early reports such as the seminal report by Portenoy and Foley estimating addiction risk during chronic opioid treatment at approximately 5%,25 higher estimates of up to 19% (this being the upper limit of addiction rates found in a systematic review by Fishbain et al), are now accepted by the medical community. There is a problem, however, with all estimates of addiction risk, and that is that iatrogenic opioid addiction (addiction arising during opioid treatment of pain), is poorly defined and understood, despite years of effort to clarify its terminology and processes. It seems that iatrogenic opioid addiction is simply what the reporting person says it is, and that the vast range of published estimates of risk reflects the lack of an agreed definition. Portenoy and Foley understood at the outset that problematic addiction is unlikely to arise when treatment is provided in a controlled, careful and supportive setting. As they said: It must be recognized that the efficacy of this therapy and its successful management may relate as much to the quality of the personal relationship between physician and patient as to the characteristics of the patient, drug, or dosing regime. As is the case with opioid maintenance for opioid addiction, a careful structured maintenance regimen is the best course for preventing the emergence of problematic opioid-seeking behaviors. It follows that observed addiction rates are likely to be higher when practice deviates from the careful controlled approach recommended in published guidelines.
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