Evidence For Efficacy

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There is evidence that opioids are effective in the treat ment of certain pain states. They are widely used in the perioperative period for the management of acute pain where dose titration to effect to accommodate interindividual requirements is the norm.4'5 The use of opioids in the management of cancer pain also appears relatively straightforward, however opioid-resistant can cer pain is now a well-recognized problem.6, 78 The major reason for the variable reports of opioid efficacy in different pain states is that pain has a multifactorial etiology and presentation. Attempting to treat acute, cancer, or chronic pain with only one modality of treatment is likely to get poor and variable results. When the cause of the pain is not clear as in many chronic pain states, the failure rate of single modality opioid therapy will be even worse.

Patients with chronic pain present with a complex paradigm. Many, if not all, have significant biological pain generators, but this may not be the predominant factor determining their pain behavior. Consequently, treatment with opioids, which may only reduce part of the pain process, may be inappropriate at best and detrimental at worst. Many countries and societies have developed guidelines9, 10 1112 in an attempt to improve the success of opioid prescribing for this group of patients. A recent epidemiological study from Denmark reporting on 228

opioid users with pain found significant negative features in terms of quality of life, when compared with 1678 nonopioid users with pain. They strongly recommend caution when long-term opioid use for pain is being considered.13

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