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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.
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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 ...