Introduction

There is increasing evidence that in some patients, opioids can relieve chronic noncancer pain (CNCP). However, the evidence is limited to relatively short-term studies which demonstrate a high drop-out rate because of opioid-related side effects or lack of efficacy. Patients who develop problems with opioid therapy, particularly those with dependency/addictive behavior traits, are time-consuming and frustrating to manage, their manipulative behavior stressing even the most tolerant staff. The long-term effects of opioids are not well quantified, but include suppression of both the immune system and the hypothalamic-pituitary axis and it is likely that their widespread use in society almost certainly leads to a greater availability for illicit use and abuse. For these reasons, proscriptive legal frameworks continue to discourage opioid prescribing. Despite this, the prescription of opioids in western countries is escalating.1,2 Unfortunately, there is only limited evidence in the literature to guide clinicians in the appropriate use of opioids for the treatment of CNCP; however, consensus guidelines on the topic have been promulgated by authoritative bodies such as The Pain Society.3

To guide everyday clinical practice, the pain physician might ask the following questions when considering the use of opioids for the treatment of CNCP.

• What is the evidence that opioids are effective in the treatment of CNCP?

• What outcome measures do I use: pain relief, improved function, or quality of life?

• Is "opioid responsiveness'' different for nociceptive or neuropathic pain (central or peripheral)?

• Are there differences between various long-acting opioids or between short- and long-acting preparations?

• Is there a place for "as-needed" opioid analgesia versus regular "by the clock'' administration?

• Is there a place for multimodal analgesia including fixed-dose combinations (e.g. codeine-acetaminophen (paracetamol), combined opioid-opioid analgesia (COOA), or antineuropathic-opioid combinations?

• Are there significant differences between the routes of opioid administration?

• How do I select a patient? Does intravenous opioid (sensitivity) testing (IVOT) play a role?

• What are the causes and consequences of opioid dose escalation? Is their a maximum ceiling dose?

• How do I treat breakthrough pain?

• What about side effects?

• What about addiction, dependency, withdrawal, and diversion?

• What are some practical tips (such as the opioid contract)?

• Is there a place for opioid rotation in CNCP?

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