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The Perceived Risks of Opioid Use

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Using opioids in chronic non-malignant pain has been regarded in some medical quarters as highly contentious. However, in the past 5 years, this practice has started to become more widespread.

Authors such as Dr. Russell Portenoy have paved the way in encouraging a new approach to this problem.

In 1999, a study at the San Francisco Spine Institute by J. Schofferman ([i]) looked at long-term opioid treatment for "severe, refractory lumbar spine pain" and concluded that this form of therapy was appropriate and useful for some patients, but noted that "this therapy is a serious commitment, probably for life."

Schofferman also stated that

"the major barriers that deter physicians from using long-term opioids for chronic non-malignant pain are the question of efficacy, and the perceived risks of tolerance, systemic toxicity, addiction, and sanctions. None of these perceived risks were a problem during this study."

In 1997, the American Academy of Pain Medicine(AAPM) and the American Pain Society(APS) jointly published a consensus statement on

"The use of opioids for the treatment of chronic pain".

The guidelines from that consensus have been used by other organisations such as the Canadian Pain Society (their consensus was published in 1998) and in America, there may be individual State guidelines.

The AAPM and APS statement clearly stated that "pain is often managed inadequately, despite the ready availability of safe and effective treatments."

They suggested that the chief impediments to use of opioids were concerns about addiction and tolerance, and risk of serious side-effects.

Reuter's Health on April 4th. 2000, reported that although opioid drugs are being used more often to treat severe, chronic pain, this rise has not led to wider drug abuse.

This has been reported ([ii]) in the April 5th. issue of the prestigious Journal of the American Medical  Association (JAMA) . Expert David Joranson of the University of Wisconsin Medical School, studied the medical use of opioids and the data on cases of drug abuse from 1990 to 1996.

The proportion of all drug abuse cases involving opioid analgesics was 3.8% in 1996 (as reported through DAWN the Drug Abuse Warning Network).

Miles Belgrade ([iii]), however, feels that

"The proportion of problem cases appears to be 10% to 15% of patients with chronic pain selected for opioid maintenance analgesia."

[i] Schofferman J Clin J Pain 1999 15(2):136-140 Long-term opioid analgesic therapy for severe refractory lumbar spine pain

[ii] Joranson et al JAMA 2000;283 :1710-1714

[iii] Belgrade MJ Postgraduate medicine 1999 106(6):115-124 Opioids for chronic nonmalignant pain Choosing suitable candidates for long-term therapy