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This chapter discusses the use of opioids in the treatment of chronic nonmalignant pain and focuses in on the vehement controversy that this subject continues to generate. The use of opioids has become well established for the treatment of cancer pain and acute pain.1–3 However, opioid use for chronic nonmalignant pain has been generally regarded as unsafe and ineffective until this past decade. More recently, these views have undergone a reappraisal driven by a number of factors, including a mounting realization that pain remains drastically undertreated. Investigations into the incidence of unrelieved pain and suffering in the United States and throughout the world prompted the National Institutes of Health to designate chronic pain as one of the most significant public health problems facing medicine.4 It is estimated to affect over 50 million Americans, and it is the presenting complaint in 80% of physician visits.5 The cost to our society of this pain and suffering, whether measured by its deleterious effect on people’s lives or in dollars and cents, is incalculable.

How is it that the strongest of painkillers, the opioids, have become so feared and stigmatized in our society. Savage has traced the U.S. experience with opioid dependence and addiction back to the 1800s when morphine was used for a variety of ailments. Those affected were predominately of the middle class, and this led to a more cautious approach with the use of opioids. The association of these drugs with sociopaths and the criminal element began after the turn of the century when large waves of immigrants crowded into American cities and opioids were used for nonmedicinal purposes as a hedge against poverty and destitution. Drug use in the United States reached epidemic proportions in the 1960s, and placed heroin on center stage with hallucinogens, marijuana, and other illicit substances. A second wave of drug use occurred in the 1980s with the introduction of PCP and crack cocaine into American society; the effect was devastating, leading to a tremendous antidrug sentiment, and out of this the War on Drugs was born.6 More recently, there has been a proliferation of interest by physicians and other health care professionals in the care of patients with pain and terminal illnesses. The advent of a new medical specialty in pain medicine and palliative care has ushered in a renewed interest for the use of opioid medications in some patient populations. The debate concerning the role of opioids in chronic pain has its roots in the cancer literature. For use in cancer patients it has been shown, rather strikingly, that opioids can impart marked degrees of pain relief along with improvement in function and quality of life, and may do so in the absence of a significant degree of tolerance, dependence, or side effects.1,2,7 Despite the fact that the cancer patient population differs in important ways from patients with chronic nonmalignant pain, it is certainly conceivable that these results may ...

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