Opioids for chronic noncancer pain

The number of available opioid preparations, each with differing chemical properties, structure and opioid receptor affinity, increases with time. The efficacy of these opioids in the treatment of pain arising from a diverse range of disorders is beyond question. With the passage of time, the list of those conditions where an opioid is recommended as a treatment option increases, and that list now includes those that generate chronic pain both of a nociceptive and neuropathic type [1]. With relatively few licensed/approved options for the analgesic management of chronic pain disorders, the availability of strong opioid formulations with such indications increases the likelihood of the practitioner selecting this type of drug as their preferred management choice. To confuse matters, licensing and approvals for drugs differ from one country to another. However, the presence of an approved indication for the use of a strong opioid in the treatment of a specific chronic pain condition does not mean that they are necessarily the best choice in that patient’s treatment plan. Has opioid treatment a place in the management of chronic pain? The answer is without doubt ‘yes’. Many, indeed most, patients will have taken an opioid early on in their treatment in the form of codeine or other weak opioid. Whether that treatment is effective, or indeed evidence based, is less certain, but the wide diversity of codeinecontaining preparations available suggests that patients and their general practitioners see merit in the use of opioids. Clearly, the pharmaceutical industry also sees these type of drugs as an important option from a commercial perspective. The issue, therefore, is whether the use of strong opioids (opioids for severe pain) has a place in the treatment of chronic pain. The answer to this question could be perceived as either ‘yes’ or ‘no’. In reality, as we will see, the wisest response may actually be ‘sometimes, but not always’. The argument falls into two sections. First, why they should be considered for the treatment of chronic pain, and second, why they should not be selected. With a fusion of this knowledge the practitioner can make a balanced judgement on the wisdom of this line of treatment.