Opioid Therapy for Chronic Nonmalignant Pain: Clinicians' Perspective

A consensus statement that acknowledges the acceptance of opioid therapy in selected patients has been endorsed by the boards of directors of both the American Pain Society and the American Academy of Pain Specialists. To evaluate the preceding debate in the pain literature, see Brena S.F. Sanders S.H. , “Opioids in Nonmalignant Pain: Questions in Search of Answers,” Clinical Journal of Pain, 7 (1991): 342–45; Chabal C. , “Narcotics for Chronic Pain: Yes or No? A Useless Dichotomy,” American Fain Society Journal, 1 (1991): 276–81; Chabal C. , “The Psychosocial Impact of Opioid Treatment,” American Pain Society Journal, 1 (1992): 289–91; Fordyce W.E. , “Opioids, Pain and Behavioral Outcomes,” American Pain Society Journal, 1 (1992): 282–84; Glynn C.J. , “Opioids in Nonmalignant Pain: Questions in Search of Answers,” Clinical Journal of Pain, 7 (1991): 346; Gourlay G.K. Cherry D.A. , “Can Opioids Be Successfully Used to Treat Severe Pain in Nonmalignant Conditions?,” Clinical Journal of Pain, 7 (1991): 347–49; Merry A.F. , “Opioids in Chronic Pain of Nonmalignant Origin: State of the Debate in New Zealand,” European Journal of Pain, 13 (1992): 39–43; Newman R.G. , “The Need to Redefine Addiction,” N. Engl. J. Med., 18 (1983): 1096–98; Portenoy R.K. , “Opioid Therapy in the Management of Chronic Back Pain,” in Tollison C.D. , ed., Interdisciplinary Rehabilitation of Low Back Pain (Baltimore: Williams & Wilkins, 1989): 137–58; Portenoy R.K. , “Opioid Therapy in Nonmalignant Pain,” Journal of Pain and Symptom Management, 5 (1990): S46–S62; Portenoy R.K. , “Chronic Opioid Therapy for Persistent Noncancer Pain: Can We Get Past the Bias?,” American Pain Society Bulletin, 1 (1991): 1–5; Portenoy R.K. , “Inadequate Outcome of Cancer Pain Treatment: Influences on Patient and Clinician Behavior,” in Part R.B. , ed., Problems in Cancer Pain Management: A Comprehensive Approach (Philadelphia: J.B. Lippincott, 1992): 119–28; Portenoy R.K. , “Opioid Therapy for Chronic Nonmalignant Pain: Current Status,” in Fields H.L. Liebeskind J.C. , eds., Progress in Pain Research and Management (Seattle: IASP Press, Vol. 1, 1994): 247–87; Portenoy R.K. , “Opioid Therapy for Chronic Nonmalignant Pain: A Review of the Critical Issues,” Journal of Pain and Symptom Management, 11 (1996): 203–17; Portenoy R.K. Payne R. , “Acute and Chronic Pain,” in Lowinson J.H. Ruiz P. Millman R.B. , eds., Substance Abuse: A Comprehensive Textbook (Baltimore: Williams & Wilkins, 1992): 691–721; Savage S.R. , “Addiction in the Treatment of Pain: Significance, Recognition, and Management,” Journal of Pain and Symptom Management, 8 (1993): 265–78; Schofferman J. , “Long-Term Use of Opioid Analgesics for the Treatment of Chronic Pain of Nonmalignant Origin,” Journal of Pain and Symptom Management, 8 (1993): 279–88; Schug S.A. Merry A.F. Acland R.H. , “Treatment Principles for the Use of Opioids in Pain of Nonmalignant Origin,” Drugs, 42 (1991): 228–39; Taub A. , “Opioid Analgesics in the Treatment of Chronic Intractable Pain of Non-Neoplastic Origin,” in Kitahata L.M. Collins D. , eds., Narcotic Analgesics in Anesthesiology (Baltimore: Williams & Wilkins, 1982): 199–208; Zenz M. , “Morphine Myths: Sedation, Tolerance, Addiction,” Postgraduate Medical Journal, 67 (1991): S100–S102; and Hagen N. , “Guidelines for Managing Chronic Non-Malignant Pain,” Canadian Family Physician Medicine, 41 (1995): 49–53.

Bonica J.J. , “Treatment of Cancer Pain: Current Status and Future Needs,” in Fields H.L. Dubner R. Cervero R. , eds., Advances in Pain Research and Therapy (New York: Raven Press, Vol. 9, 1985): 589–616; Jorgensen L. , “Treatment of Cancer Pain Patients in a Multidisciplinary Pain Clinic,” Pain Clinic, 3 (1990): 83–89; Moulin D.E. Foley K.M. , “Review of a Hospital-Based Pain Service,” in Foley K.M. Bonica J.J. Ventafridda V. , eds., Advances in Pain Research and Therapy, Second International Congress on Cancer Pain (New York: Raven Press, Vol. 16, 1990): 413–27; Portenoy R.K. , “Cancer Pain: Epidemiology and Syndromes,” Cancer, 63 (1989): 2298–307; Schug S.A. Zech D. Dorr U. , “Cancer Pain Management According to WHO Analgesic Guidelines,” Journal of Pain and Symptom Management, 5 (1990): 27–32; Schug S.A. , “A Long-Term Survey of Morphine in Cancer Pain Patients,” Journal of Pain and Symptom Management, 7 (1992): 259–66; Takeda F. , “Results of Field Testing in Japan of the WHO Draft Interim Guidelines on Relief of Cancer Pain,” Pain Clinic, 1 (1986): 83–89; Toscani F. Carini M. , “The Implementation of WHO Guidelines for the Treatment of Advanced Cancer Pain at a District General Hospital in Italy,” Pain Clinic, 3 (1989): 37–48; Ventafridda V. Tamburini M. DeConno F. , “Comprehensive Treatment in Cancer Pain,” in Fields H.L. Dubner R. Cervero F. , eds., Advances in Pain Research and Therapy (New York: Raven Press, Vol. 9, 1985): 617–28; Ventafridda V. , “A Validation Study of the WHO Method for Cancer Pain Relief,” Cancer, 59 (1987): 850–56; Vijayaram S. , “Experience with Oral Morphine for Cancer Pain Relief,” Journal of Pain and Symptom Management, 4 (1989): 130–34; Walker V.A. , “Evaluation of WHO Analgesic Guidelines for Cancer Pain in a Hospital-Based Palliative Care Unit,” Journal of Pain and Symptom Management, 3 (1988): 145–49; World Health Organization, Cancer Pain Relief (Geneva: World Health Organization, 1986); World Health Organization, Cancer Pain Relief and Palliative Care (Geneva: World Health Organization, 1990); and World Health Organization, Cancer Pain Relief, With a Guide to Opioid Availability (Geneva: World Health Organization, 2nd ed., 1996).

Portenoy R.K. , “Pain and Quality of Life: Theoretical Aspects,” in Osoba D. , ed., Quality of Life in Cancer Patients (New York: CRC Publ., 1991): 279–92; and Ventafridda V. , “Pain and Quality of Life Assessment in Advanced Cancer Patients,” in Ventafridda V. , eds., Assessment of Quality of Life and Cancer Treatment (Amsterdam: Excerpta Medica, 1986): 183–92.

American Pain Society, Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain (Skokie: American Pain Society, 3rd ed., 1992); Angell M. , “The Quality of Mercy,” N. Engl. J. Med., 306 (1982): 98–99; Foley K.M. , “The Relationship of Pain and Symptom Management to Patient Requests for Physician-Assisted Suicide,” Journal of Pain and Symptom Management, 6 (1991): 289–97; Health and Public Policy Committee, American College of Physicians, “Drug Therapy for Severe Chronic Pain in Terminal Illness,” Annals of Internal Medicine, 99 (1983): 870–73; McGivney W.T. Crooks G.M. , “The Care of Patients with Severe Chronic Pain in Terminal Illness,” JAMA, 251 (1984): 1182–88; Morgan J.P. , “American Opiophobia: Customary Underutilization of Opioid Analgesics,” Advances in Alcohol and Substance Abuse, 5 (1985): 163–73; Portenoy (1992), supra note 1; Stjernsward J. , “Cancer Pain Relief: An Important Global Public Health Issue,” in Fields H.L. Dubner R. Cervero F. , eds., Advances in Pain Research and Therapy (New York: Raven Press, Vol. 9, 1985): 555–58; Swerdlow M. Stjernsward J. , “Cancer Pain Relief—An Urgent Problem,” World Health Forum, 3 (1982): 325–30; World Health Organization (1986), supra note 2; World Health Organization (1990), supra note 2; World Health Organization (1996), supra note 2; and Zenz M. Sorge J. , “Is the Therapeutic Use of Opioids Adversely Affected by Prejudice and Law?,” Recent Results in Cancer Research, 121 (1991): 43–50.

Clark H.W. Sees K.L. , “Opioids, Chronic Pain and the Law,” Journal of Pain and Symptom Management, 8 (1993): 297–305; Haislip G.R. , “Impact of Drug Abuse on Legitimate Drug Use,” in Hill C.S. Fields W.S. , eds., Advances in Pain Research and Therapy (New York: Raven Press, Vol. 11, 1989): 205–11; and Hill C.S. , “Influence of Regulatory Agencies on the Treatment of Pain and Standards of Medical Practice for the Use of Narcotics,” Pain Digest, 1 (1991): 7–12.

Angarola R.T. Wray S.D. , “Legal Impediments to Cancer Pain Treatment,” in Hill C.S. Fields W.S. , eds., Advances in Pain Research and Therapy (New York: Raven Press, Vol. 11, 1989): 213–31; Edwards W.T. , “Optimizing Opioid Treatment of Postoperative Pain,” Journal of Pain and Symptom Management, 5 (1990): S24–S36; Hill C.S. , “Relationship Among Cultural, Educational and Regulatory Agency Influence on Optimum Cancer Pain Treatment,” Journal of Pain and Symptom Management, 5 (1990): S37–S45; Hill , supra note 5; Morgan , supra note 4; Portenoy (1992), supra note 1; and Zenz Sorge , supra note 4.

Weissman D.E. Joranson D.E. Hopwood M.B. , “Wisconsin Physicians' Knowledge and Attitudes About Opioid Analgesic Regulations,” Wisconsin Medical Journal, 90 (1991): 671–75.

Gitchel G.T. , “Existing Methods to Identify Retail Drug Diversion,” in Cooper J.R. Czechowicz D.J. Molinari S.P. , eds., Impact of Prescription Drug Diversion Control Systems on Medical Practice and Patient Care (Washington, D.C.: U.S. Government Printing Office, National Institute on Drug Abuse, Research Mono. 131, 1993): 132–40.

United States Department of Justice, Drug Enforcement Administration: Multiple Copy Prescription Program Resource Guide (Washington, D.C.: U.S. Government Printing Office, 1987).

Angarola Wray , supra note 6; Cooper J.R. , “Prescription Drug Diversion Control and Medical Practice,” JAMA, 268 (1992): 1306–10; Portenoy R.K. , “The Effect of Drug Regulation on the Management of Cancer Pain,” New York State Journal of Medicine, 91 (1991): 13S–18S; and Reidenberg M.M. , “Effect of the Requirement for Triplicate Prescriptions for Benzodiazepines in New York State,” Clinical Pharmacology and Therapeutics, 50 (1991): 129–31.

Jacob T.R. , “Multiple Copy Prescription Regulation and Drug Abuse: Evidence from the DAWN Network,” in Wilford B.B. , ed., Balancing the Response to Prescription Drug Abuse (Chicago: American Medical Association, 1990): 205–17.

Sigler K.A. , “Effects of a Triplicate Prescription Law on Prescribing of Schedule II Drugs,” American Journal of Hospital Pharmacology, 41 (1984): 108–11; and Weintraub M. , “Consequences of the 1989 New York State Triplicate Benzodiazepine Prescription Regulations,” JAMA, 266 (1991): 2392–97.

Joranson D.E. , “Opioids for Chronic Cancer and Non-Cancer Pain: A Survey of State Medical Board Members,” Federal Bulletin, 4 (1992): 15–49.

Thurel C. Bardin T. Boccard E. , “Analgesic Efficacy of an Association of 500 mg Paracetamol Plus 30 mg Codeine Versus 400 mg Paracetamol Plus 30 mg Dextropropoxyphene in Repeated Doses for Chronic Lower Back Pain,” Current Therapy and Research, 50 (1991) 463–73; Vlok G.J. Van Vuren J.P. , “Comparison of a Standard Ibuprofen Treatment Regimen with a New Ibuprofen/Paracetamol/Codeine Combination in Chronic Osteoarthritis,” South Africa Medical Journal, 1 Supp. (1987): 1–6; Arkinstall W. , “Efficacy of Controlled-Release Codeine in Chronic Non-Malignant Pain: A Randomized, Placebo-Controlled Clinical Trial,” Pain, 62 (1995): 169–78; Boissier C. , “Acceptability and Efficacy of Two Associations of Paracetamol with a Central Analgesic (Dextropropoxyphene or Codeine): Comparison in Osteoarthritis,” Journal of Clinical Pharmacology, 32 (1992): 990–95; and Lloyd R.S. , “The Efficacy and Tolerability of Controlled-Release Dihydrocodeine Tablets and Combination Dextro-propoxyphene Paracetamol Tablets in Patients with Severe Osteoarthritis of the Hips,” Current Medical Research Opinion, 13 (1992): 37–48.

Moulin D.E. , “Randomised Trial of Oral Morphine for Chronic Non-Cancer Pain,” Lancet, 347 (1996): 143–47.

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See Zenz Strumpf Tryba , id.

See Brookoff Palomano , supra note 16.

Buckley F.P. Sizemore W.A. Charlton J.E. , “Medication Management in Patients with Chronic Non-Malignant Pain. A Review of the Use of a Drug Withdrawal Protocol,” Pain, 26 (1986): 153–66; Finlayson R.D. Maruta T. Morse B.R. , “Substance Dependence and Chronic Pain: Profile of 50 Patients Treated in an Alcohol and Drug Dependence Unit,” Pain, 26 (1986): 167–74; Finlayson R.D. , “Substance Dependence and Chronic Pain: Experience with Treatment and Follow-Up Results,” Pain, 26 (1986): 175–80; Maruta T. , “Prescription Drug-Induced Organic Brain Syndrome,” American Journal of Psychiatry, 135 (1978): 376–77; Maruta T. Swanson D.W. , “Problems with the Use of Oxycodone Compound in Patients with Chronic Pain,” Pain, 11 (1981): 389–96; Maruta T. Swanson D.W. Finlayson R.E. , “Drug Abuse and Dependency in Patients with Chronic Pain,” Mayo Clinic Proceedings, 54 (1979): 241–44; McNairy S.L. , “Prescription Medication Dependence and Neuropsychologic Function,” Pain, 18 (1984): 169–77; Ready L.B. Sarkis E. Turner J.A. , “Self-Reported vs. Actual Use of Medications in Chronic Pain Patients,” Pain, 12 (1982): 285–94; and Turner J.A. , “Drug Utilization Pattern in Chronic Pain Patients,” Pain, 12 (1982): 357–63.

See Portenoy (1990), supra note 1.

Galer B.S. , “Individual Variability in the Response to Different Opioids: Report of Five Cases,” Pain, 49 (1992): 87–91.

Bruera E. , “The Edmonton Staging System for Cancer Pain: Preliminary Report,” Pain, 37 (1989): 203–10; and Mercadante S. , “Predictive Factors in Advanced Cancer Pain Treated Only by Analgesics,” Pain, 50 (1992): 151–55.

Amer S. Meyerson B.A. , “Lack of Analgesic Effect of Opioids on Neuropathic and Idiopathic Forms of Pain,” Pain, 33 (1988): 11–23; Bruera , id.; Kupers R.C. , “Morphine Differentially Affects the Sensory and Affective Pain Ratings in Neurogenic and Idiopathic Forms of Pain,” Pain, 47 (1991): 5–12; and Moulin Foley , supra note 2.

Cherny N.I. , “Opioid Responsiveness of Cancer Pain Syndromes Caused by Neuropathic or Nociceptive Mechanisms: A Combined Analysis of Controlled Single Dose Studies,” Neurology, 44 (1994): 857–61; Galer , supra note 21; Jadad A.R. , “Morphine Responsiveness of Chronic Pain: Double-Blind Randomised Crossover Study with Patient-Controlled Analgesia,” Lancet, 339 (1992): 1367–71; McQuay H.J. , “Opioid Sensitivity of Chronic Pain: A Patient-Controlled Analgesia Method,” Anaesthesia, 47 (1992): 757–67; Mercadante , supra note 22; Portenoy (1990), supra note 1; Portenoy Foley , supra note 16; Rowbotham M.C. Reisner-Keller L.A. Fields H.L. , “Both Intravenous Lidocaine and Morphine Reduce the Pain of Postherapeutic Neuralgia,” Neurology, 41 (1991): 1024–28; Urban , supra note 16; and Zenz Strumpf Tryba , supra note 16.

Louie A.K. Way E.L. , “Overview of Opiate Tolerance and Physical Dependence,” in Almeida O.F. Shippenberg T.S. , eds., Neurobiology of Opioids (New York: Springer-Verlag, 1991).

See Portenoy (1989), supra note 1.

Brescia F.J. , “Pain, Opioid Use and Survival in Hospitalized Patients with Advanced Cancer,” Journal of Clinical Oncology, 10 (1992): 149–55; Foley K.M. , “Changing Concepts of Tolerance to Opioids: What the Cancer Patient Has Taught Us,” in Chapman C.R. Foley K.M. , eds., Current and Emerging Issues in Cancer Pain: Research and Practice (New York: Raven Press, 1993): 331–50; France Urban Keefe , supra note 16; Hill , supra note 6; Kanner R.M. Foley K.M. , “Patterns of Narcotic Drug Use in a Cancer Pain Clinic,” Annals of the New York Academy of Science, 362 (1981): 161–72; Krames Lanning , supra note 16; Onofrio B.M. Yaksh T.L. , “Long-Term Pain Relief Produced by Intrathecal Morphine Infusion in 53 Patients,” Journal of Neurosurgery, 72 (1990): 200–09; Plummer , supra note 16; Portenoy Foley , supra note 16; Schug , supra note 1; Taub , supra note 1; Twycross R.G. , “Clinical Experience with Diamorphine in Advanced Malignant Disease,” International Journal of Optical Pharmacology, Therapy and Toxicology, 9 (1974): 184–98; and Urban , supra note 16.

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See Kreek (1973), supra note 31; and Kreek (1978), supra note 31.

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See Bruera , supra note 22.

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Buckley Sizemore Charlton , supra note 19; Halpern L.M. Robinson J. , “Presenting Practices for Pain in Drug Dependence: A Lesson in Ignorance,” Advanced Alcohol Substance Abuse, 5 (1985): 184–97; and Kanner Foley , supra note 27.

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See Clark Sees , supra note 5.

See Rinaldi , supra note 41.

See Portenoy (1992), supra note 1.

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