Using opioid analgesics to manage chronic noncancer pain in primary care.

BACKGROUND Opioid analgesics have been considered the drugs of choice for the treatment of moderate to severe cancer and postoperative pain. Cultural attitudes and concerns about abuse have inhibited their use for a larger population of patients who have chronic noncancer pain. METHODS Medical literature was searched from 1990 to 1998 using the key words "opioid analgesics," "opioid abuse," and "chronic pain." I have also drawn from more than 20 years of experience prescribing opioid analgesics for chronic pain. A case series analysis of 30 patients using opioid analgesics for periods ranging from 6 months to 17 years was performed. RESULTS AND CONCLUSIONS The World Health Organization has published a "three-step ladder" guide to treatment of cancer pain graded from mild to severe; this guide can be readily applied to the treatment of pain from all sources. Opioid analgesics are the mainstay of treatment for moderate to severe pain. Chronic pain patients offer some difficult challenges for busy primary care physicians. The unique pharmacologic characteristics of opioid medications are important in outpatient management. A four-sheet office management protocol helps to focus efficiently on important clinical issues related to pain control, to monitor for opiate abuse, and to incorporate pain management more effectively in the overall primary care plan of the patient.