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• W2155442308 abstract "Opioids are the most potent and effective analgesics available and have become accepted as appropriate treatment for acute and cancer pain. However, there is concern regarding their usage in chronic non-cancer pain because of fears that they are ineffective in the long-term, that their use will lead to a deterioration in the patient’s condition and that the medical prescription of opioids will lead to an increase in their non-medical use within society. In certain countries, physicians may also fear triggering scrutiny and sanctions by regulatory agencies when prescribing long-term opioids for chronic pain of non-malignant origin.18Clark HW Sees KL Opioids, chronic pain, and the law.J Pain Symp Manage. 1993; 8: 297-305Abstract Full Text PDF PubMed Scopus (30) Google Scholar 48Joranson DE Gilson AM Controlled substances, medical practice, and the law.in: Schwartz HI Psychiatric Practice Under Fire: The Influence of Government, the Media and Special Interests on Somatic Therapies. American Psychiatric Press, Inc., Washington, DC1994: 173-194Google Scholar 92Turk DC Brody MC What position do APS’s physicians take on chronic opioid therapy?.Am Pain Soc Bull. 1992; 2: 1-5Google Scholar However, relief of pain is a humanitarian issue and it has been said that ‘to leave a person in avoidable pain and suffering should be regarded as a serious breach of fundamental human rights’.87Somerville MA Opioids for chronic pain of non-malignant origin—coercion or consent?.Health Care Anal. 1995; 3: 12-14Crossref PubMed Scopus (12) Google Scholar Chronic pain is a common complaint within the community and a common cause of distress and disability. A telephone survey of 1037 randomly selected households in the UK concluded that, out of a total household population of 2942 individuals, 208 adults (7%) experienced intermittent or persistent pain from non-fatal causes that lasted for at least 3 months.8Bowsher D Rigge M Sopp L Prevalence of chronic pain in the British population: a telephone survey of 1037 households.Pain Clin. 1991; 4: 223-231Google Scholar Fifty-five per cent stated they were unable to lead a normal life because of the pain. A recent Scottish study indicated a higher incidence of chronic pain or discomfort (46.5%) in the community.27Elliot AM Smith BH Penny KI Smith WC Chambers WA The epidemiology of chronic pain in the community.Lancet. 1999; 354: 1248-1252Abstract Full Text Full Text PDF PubMed Scopus (944) Google Scholar Half of those in pain had severe or disabling pain. Back pain and arthritis were the most common causes of pain, accounting for one-third of all complaints. Chronic pain was associated with older age, retirement, or inability to work. Other studies amply demonstrate that recurrent and chronic pain is a major public health problem.24Crombie IK Epidemiology of persistent pain.in: Jensen TS Turner JA Wiesenfeld-Hallin Z Proceedings of the 8th World Congress on Pain. IASP Press, Seattle1997: 53-61Google Scholar Poor management of such pain has important consequences for individual patients, their families, and society. Sorenson and colleagues investigated the use of opioids outside hospitals in Denmark.88Sorenson HT Rasmussen HH Moller-Petersen JF Ejlersen E Hamburger H Olesen F Epidemiology of pain requiring strong analgesics outside hospital in a geographically defined population in Denmark.Danish Med Bull. 1992; 39: 464-467PubMed Google Scholar Their sample of 480 000 represented almost 10% of the Danish population. During the 1-month study period, strong opioids were prescribed to 633 patients (0.2% population). In 110 patients (17%), the indication was pain as a result of malignancy. In 387 patients (58%), the indication was for chronic non-malignant painful conditions, which included back pain (25%), headache (10%), arthritis (9%), pancreatitis (6%), angina pectoris (5%), and phantom pain (5%). In 69 patients, strong opioid was prescribed for recurrent acute pain—the most common indication being migraine. They concluded that only a small number of patients with chronic pain within the community (estimated prevalence 30%) were being treated with strong opioids. In Australia, over a 10-yr period from 1986 to 1996, the amount of oral morphine consumed for pain control increased fivefold from 117 to 578 kg. Use in non-malignant pain accounted for much of this increase. In a sample of patients being treated with opioids for non-cancer pain, one-third continued using opioids for 5 yr or more and this usage was associated with dose escalation. Many patients had poorly defined medical problems and social and emotional problems were common.6Bell JR Australian trends in opioid prescribing for non-cancer pain, 1986–1996.Med J Aust. 1997; 167: 26-29PubMed Google Scholar There have been several surveys of opioid prescribing habits for non-malignant pain amongst pain management specialists. In the UK, Coniam surveyed physician members of the Intractable Pain Society regarding opioid prescription for non-malignant pain. Sixty-two per cent of respondents indicated that they did prescribe opioids for non-malignant pain, the predominant reason being failure of other treatments. However, 81% reported some problems with patients on long-term opioid therapy, the most frequent being intolerance to side effects, which was reported by 63.8% of respondents.23Coniam SW Prescribing opioids for chronic pain in non-malignant disease.in: Tywcross RG The Edinburgh Symposium on Pain Control and Medical Education. Royal Society of Medicine International Congress and Symposium Series. 149. Royal Society of Medicine, London1989: 205-210Google Scholar The Clinical Standards Advisory Group (CSAG) study ‘Services for patients with pain’ reported that 75% of pain management clinics in the UK currently provide supervised opioid therapy for non-cancer pain.19Clinical Standards Advisory Group ‘Services for Patients with Pain’. Department of Health, London2000Google Scholar Turk and Brody surveyed members of the American Pain Society and reported that 83% maintained some patients on opioid therapy. Generally, the respondents believed that opioids were under-utilized and that addiction was over-emphasized.92Turk DC Brody MC What position do APS’s physicians take on chronic opioid therapy?.Am Pain Soc Bull. 1992; 2: 1-5Google Scholar However, pain specialists do not treat most patients with pain. A random sample of 6962 American doctors from seven specialities (excluding pain management) suggested that the respondents (1912 doctors) relatively infrequently prescribed opioids for patients with chronic non-cancer pain.91Turk DC Brody MC Okifuji EA Physicians’ attitudes and practices regarding the long-term prescribing of opioids for non-cancer pain.Pain. 1994; 59: 201-208Abstract Full Text PDF PubMed Scopus (168) Google Scholar Rheumatologists treated more chronic pain patients and prescribed long-term opioids more frequently than any other speciality in the survey. The triggers for a doctor to prescribe opioids for a particular patient requires further investigation. Data from patients attending a pain treatment centre suggest that prescribing practice did not appear to be influenced either by the extent of pathology or by pain severity. Patients who displayed high levels of observable pain behaviours and reported high levels of functional impairment were significantly more likely to be prescribed opioids.93Turk DC Okifuji A What factors affect physicians’ decisions to prescribe opioids for chronic noncancer pain patients?.Clin J Pain. 1997; 13: 330-336Crossref PubMed Scopus (145) Google Scholar There is a clinical impression in the UK that opioids are only given as a last resort. Yet in 1995, 4.13 million prescriptions for opioids were written in England alone. Published patient surveys and case-reports support the efficacy and safety of long-term opioid analgesics in carefully selected patients with chronic non-malignant nociceptive and neuropathic pain.7Bouckoms AJ Masand P Murray GB Cassem EH Stern TA Tesar GE Chronic nonmalignant pain treated with long-term oral narcotic analgesics.Ann Clin Psychiatry. 1992; 4: 185-192Crossref Scopus (58) Google Scholar 35France RD Urban BJ Keefe FJ Long-term use of narcotic analgesics in chronic pain.Soc Sci Med. 1984; 19: 1379-1382Crossref PubMed Scopus (108) Google Scholar 68Portenoy RK Foley KM Chronic use of opioid analgesics in non-malignant pain: report of 38 cases.Pain. 1986; 25: 171-186Abstract Full Text PDF PubMed Scopus (702) Google Scholar 84Simpson RK Edmondson EA Constant CF Collier C Transdermal fentanyl as treatment for chronic low back pain.J Pain Symptom Manage. 1997; 14: 218-224Abstract Full Text PDF PubMed Scopus (97) Google Scholar 89Taub A Opioid analgesics in the treatment of chronic intractable pain of non-neoplastic origin.in: Kitahata LM Collins JG Narcotic Analgesics in Anesthesiology. Williams & Wilkins, Baltimore/London1982: 199-208Google Scholar 90Tennant F Robinson D Sagherian A Seecof R Chronic opioid treatment of intractable, non-malignant pain.NIDA Res Monogr. 1998; 81: 174-180Google Scholar 96Urban BJ France RD Steinberger EK Scott DL Maltbie AA Long-term use of narcotic/antidepressant medication in the management of phantom limb pain.Pain. 1986; 24: 191-196Abstract Full Text PDF PubMed Scopus (121) Google Scholar 102Zenz M Strumpf Tryba M Long-term oral opioid therapy in patients with chronic nonmalignant pain.J Pain Symptom Manage. 1992; 7: 69-77Abstract Full Text PDF PubMed Scopus (352) Google Scholar Patients themselves report positive preference for opioid medication.2Arkinstall W Sandler A Goughnour B Babul N Harsanyi Z Darke A Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial.Pain. 1995; 62: 169-178Abstract Full Text PDF PubMed Scopus (165) Google Scholar 45Jamieson RN Anderson KO Peeters-Asdourian C Ferrante FM Survey of opioid use in chronic nonmalignant pain patients.Reg Anaesth. 1994; 19: 225-230Google Scholar 98Watson CP Babul N A randomized trial in postherpetic neuralgia.Neurology. 1998; 50: 1837-1841Crossref PubMed Google Scholar A criteria-based methodological assessment of eight randomized controlled trials (RCT) of efficacy of opioids in non-malignant pain has recently been reported.37Graven S de Vet HCW van Kleefe M Weber WEJ Opioids in chronic non-malignant pain: a criteria-based review of the literature.in: Devor M Rowbotham MC Wiesenfeld-Hallin Z Proceedings of the 9th World Congress on Pain. Progress in Pain Research and Management. Volume 16. IASP Press, Seattle2000: 965-972Google Scholar Methodo logical quality of the trials was assessed and agreed by three independent reviewers against 14 criteria and the types of pain (nociceptive, neuropathic, or idiopathic) studied in each trial were identified (Table 1). Some of these trials are infusion or injection studies and some are longer-term studies of oral or sublingual opioids.Table 1Overall outcome of RCTs on opioid therapy for different chronic non-cancer pain syndromes.37 +=positive effect; –=no effect; #=significant adverse effects (adapted from Graven et al.37)Pain typeReferenceControlResultsNociceptiveArner and Meyerson3Arner S Meyerson BA Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain.Pain. 1988; 33: 11-23Abstract Full Text PDF PubMed Scopus (913) Google Scholarplacebo+Kjaersgaard-Andersen and colleagues49Kjaersgaard-Andersen P Nafei A Skov O Madsen F Andersen HM Kroner K Hvass I Gjodereum O Pedersen L Branebjerg PE Codeine plus paracetamol versus paracetamol in longer-term treatment of chronic pain due to osteoarthritis of the hip. A randomised, double-blind, multi-centre study.Pain. 1990; 43: 303-318Abstract Full Text PDF Scopus (119) Google Scholarparacetamol+#NeuropathicArner and Meyerson3Arner S Meyerson BA Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain.Pain. 1988; 33: 11-23Abstract Full Text PDF PubMed Scopus (913) Google Scholarplacebo–Dellemijin and Vanneste26Dellemijin PL Vanneste JAL Randomised double-blind active-placebo-controlled crossover trial of intravenous fentanyl in neuropathic pain.Lancet. 1997; 349: 753-758Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholarplacebo/diazepam+Kupers and colleagues52Kupers RC Konings H Adriaensen H Gybels JM Morphine differentially affects the sensory and affective pain ratings in neuropathic and idiopathic forms of pain.Pain. 1991; 47: 5-12Abstract Full Text PDF PubMed Scopus (180) Google Scholarplacebo+Rowbotham and colleagues76Rowbotham MC Reisner-Keller LA Fields HL Both intravenous lidocaine and morphine reduce the pain of post-herpetic neuralgia.Neurology. 1991; 41: 1024-1028Crossref PubMed Google Scholarplacebo/lignocaine+IdiopathicArner and Myerson3Arner S Meyerson BA Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain.Pain. 1988; 33: 11-23Abstract Full Text PDF PubMed Scopus (913) Google Scholarplacebo–Kupers and colleagues52Kupers RC Konings H Adriaensen H Gybels JM Morphine differentially affects the sensory and affective pain ratings in neuropathic and idiopathic forms of pain.Pain. 1991; 47: 5-12Abstract Full Text PDF PubMed Scopus (180) Google Scholarplacebo–Moulin and colleagues60Moulin DE Iezzi A Amireh R Sharpe WKJ Boyd D Mersky H Randomised trial of oral morphine for chronic non-cancer pain.Lancet. 1996; 347: 143-147Abstract PubMed Scopus (379) Google Scholarbenztropine+#UnspecifiedArkinstall and colleagues2Arkinstall W Sandler A Goughnour B Babul N Harsanyi Z Darke A Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial.Pain. 1995; 62: 169-178Abstract Full Text PDF PubMed Scopus (165) Google Scholarplacebo+#Mays and colleagues55Mays KS Lipmann JJ Schnapp M Local analgesia without anaesthesia using peripheral perineural morphine injections.Anaesth Analg. 1987; 66: 417-420Crossref PubMed Scopus (80) Google Scholarbupivacaine/placebo+ Open table in a new tab The authors concluded from these trials that nociceptive pain responds well to opioid therapy3Arner S Meyerson BA Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain.Pain. 1988; 33: 11-23Abstract Full Text PDF PubMed Scopus (913) Google Scholar 49Kjaersgaard-Andersen P Nafei A Skov O Madsen F Andersen HM Kroner K Hvass I Gjodereum O Pedersen L Branebjerg PE Codeine plus paracetamol versus paracetamol in longer-term treatment of chronic pain due to osteoarthritis of the hip. A randomised, double-blind, multi-centre study.Pain. 1990; 43: 303-318Abstract Full Text PDF Scopus (119) Google Scholar and that neuropathic pain responds reasonably well, although slightly less favourably.3Arner S Meyerson BA Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain.Pain. 1988; 33: 11-23Abstract Full Text PDF PubMed Scopus (913) Google Scholar 26Dellemijin PL Vanneste JAL Randomised double-blind active-placebo-controlled crossover trial of intravenous fentanyl in neuropathic pain.Lancet. 1997; 349: 753-758Abstract Full Text Full Text PDF PubMed Scopus (205) Google Scholar 52Kupers RC Konings H Adriaensen H Gybels JM Morphine differentially affects the sensory and affective pain ratings in neuropathic and idiopathic forms of pain.Pain. 1991; 47: 5-12Abstract Full Text PDF PubMed Scopus (180) Google Scholar 76Rowbotham MC Reisner-Keller LA Fields HL Both intravenous lidocaine and morphine reduce the pain of post-herpetic neuralgia.Neurology. 1991; 41: 1024-1028Crossref PubMed Google Scholar Patients with so-called idiopathic pain tend not to respond to opioids.3Arner S Meyerson BA Lack of analgesic effect of opioids on neuropathic and idiopathic forms of pain.Pain. 1988; 33: 11-23Abstract Full Text PDF PubMed Scopus (913) Google Scholar 52Kupers RC Konings H Adriaensen H Gybels JM Morphine differentially affects the sensory and affective pain ratings in neuropathic and idiopathic forms of pain.Pain. 1991; 47: 5-12Abstract Full Text PDF PubMed Scopus (180) Google Scholar 60Moulin DE Iezzi A Amireh R Sharpe WKJ Boyd D Mersky H Randomised trial of oral morphine for chronic non-cancer pain.Lancet. 1996; 347: 143-147Abstract PubMed Scopus (379) Google Scholar Patients tended to report favourable effects from opioids in the two studies that did not specify the diagnoses.2Arkinstall W Sandler A Goughnour B Babul N Harsanyi Z Darke A Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial.Pain. 1995; 62: 169-178Abstract Full Text PDF PubMed Scopus (165) Google Scholar 55Mays KS Lipmann JJ Schnapp M Local analgesia without anaesthesia using peripheral perineural morphine injections.Anaesth Analg. 1987; 66: 417-420Crossref PubMed Scopus (80) Google Scholar Jadad has recently conducted a systematic review of randomized controlled clinical trials of opioids in neuropathic pain.43Jadad AR Opioids in the treatment of neuropathic pain: A systematic review of controlled clinical trials.in: Bruera E Portenoy RK Topics in Palliative Care. Oxford University Press, New York1998: 31-40Google Scholar He identified nine trials that evaluated 104 patients in total. The trials had small sample sizes, heterogeneous patient populations, and designs. Some of the trials used fixed dose administration and, in some, the dose was titrated. However, he concluded that the best available evidence appears to support the contention that neuropathic pain can respond to opioids. Table 2 shows the reported efficacy of opiates on different pain syndromes from prospective uncontrolled trials.37Graven S de Vet HCW van Kleefe M Weber WEJ Opioids in chronic non-malignant pain: a criteria-based review of the literature.in: Devor M Rowbotham MC Wiesenfeld-Hallin Z Proceedings of the 9th World Congress on Pain. Progress in Pain Research and Management. Volume 16. IASP Press, Seattle2000: 965-972Google Scholar These studies reveal similar results to the RCT and, as expected, the positive effects from these trials are larger and more frequent than in the prospective controlled series.Table 2Overall efficacy of opiates on different pain syndromes (prospective uncontrolled studies).37Graven S de Vet HCW van Kleefe M Weber WEJ Opioids in chronic non-malignant pain: a criteria-based review of the literature.in: Devor M Rowbotham MC Wiesenfeld-Hallin Z Proceedings of the 9th World Congress on Pain. Progress in Pain Research and Management. Volume 16. IASP Press, Seattle2000: 965-972Google Scholar +=positive effect; –=no effect; +/–=mixed effectsPain typeReferenceResultsNociceptiveMcQuay and colleagues58McQuay H Jadad AR Carroll D Faura C Glynn CJ Moore RA Liu Y Opioid sensitivity of chronic pain: a patient-controlled analgesia method.Anaesthesia. 1992; 47: 757-767Crossref PubMed Scopus (78) Google Scholar+NeuropathicFenollosa and colleagues31Fenollosa P Pallares J Cervera J Pelegrin F Inigo V Giner M Forner V Chronic pain in the spinal cord injured: statistical approach and pharmacological treatment.Paraplegia. 1993; 31: 722-729Crossref PubMed Scopus (96) Google Scholar+McQuay and colleagues58McQuay H Jadad AR Carroll D Faura C Glynn CJ Moore RA Liu Y Opioid sensitivity of chronic pain: a patient-controlled analgesia method.Anaesthesia. 1992; 47: 757-767Crossref PubMed Scopus (78) Google Scholar+/–Urban and colleagues96Urban BJ France RD Steinberger EK Scott DL Maltbie AA Long-term use of narcotic/antidepressant medication in the management of phantom limb pain.Pain. 1986; 24: 191-196Abstract Full Text PDF PubMed Scopus (121) Google Scholar+IdiopathicMcQuay and colleagues58McQuay H Jadad AR Carroll D Faura C Glynn CJ Moore RA Liu Y Opioid sensitivity of chronic pain: a patient-controlled analgesia method.Anaesthesia. 1992; 47: 757-767Crossref PubMed Scopus (78) Google Scholar–Not specified or mixedAuld and colleagues4Auld AW Maki-Jokela A Murdoch DM Intraspinal narcotic analgesia in the treatment of chronic pain.Spine. 1985; 10: 777-781Crossref PubMed Scopus (73) Google Scholar+Gilmann and Lichtigfeld36Gilmann MA Lichtigfeld FJ A comparison of the effects of morphine sulphate and nitrous oxide analgesia on chronic pain states in man.J Neurological Sci. 1981; 49: 41-45Abstract Full Text PDF PubMed Scopus (40) Google Scholar+Penn and Paice64Penn RD Paice JA Chronic intrathecal morphine for intractable pain.J Neurosurg. 1987; 67: 182-186Crossref PubMed Scopus (183) Google Scholar+Plummer and colleagues67Plummer JL Cherry DA Cousins MJ Gourlay GK Onley MM Evans KHA Long-term spinal administration of morphine in cancer and non-cancer pain: a retrospective study.Pain. 1991; 44: 215-220Abstract Full Text PDF PubMed Scopus (105) Google Scholar+/– Open table in a new tab A recent review of the limited literature regarding opioid efficacy in ischaemic pain has concluded that further research is needed before recommendations can be made.66Persson J Opioids in ischaemic pain.in: Kalso E McQuay H Wiesenfeld-Hallin Z Opioid Sensitivity of Chronic Noncancer pain. Progress in Pain Research and Mechanisms. Volume 14. IASP Press, Seattle1999: 337-347Google Scholar Brena has argued that the needs of the chronic pain patient include not only reduction in subjective discomfort but also increase in general level of functioning, improvement in lifestyle, decrease in environmental stress and return to work. Whilst the first need may be met through opioid analgesia, he questions how well the other needs will be met.9Brena SF Sanders SH Opioids in nonmalignant pain: questions in search of answers.Clin J Pain. 1991; 7: 342-345Crossref PubMed Scopus (45) Google Scholar Completion of a multidisciplinary pain rehabilitation programme can result in a significant reduction in use and misuse of medications. This reduction can be associated with a decrease in pain intensity, an improved sense of well-being and an increase in physical activity, return to work and ability to manage pain and related problems.9Brena SF Sanders SH Opioids in nonmalignant pain: questions in search of answers.Clin J Pain. 1991; 7: 342-345Crossref PubMed Scopus (45) Google Scholar 32Finlayson RE Maruta T Morse RM Martin MA Substance dependence and chronic pain: experience with treatment and follow-up results.Pain. 1986; 26: 175-180Abstract Full Text PDF PubMed Scopus (48) Google Scholar Conflicting results have been obtained from studies investigating the effects of chronic opioid therapy on physical and psychological functioning.2Arkinstall W Sandler A Goughnour B Babul N Harsanyi Z Darke A Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial.Pain. 1995; 62: 169-178Abstract Full Text PDF PubMed Scopus (165) Google Scholar 35France RD Urban BJ Keefe FJ Long-term use of narcotic analgesics in chronic pain.Soc Sci Med. 1984; 19: 1379-1382Crossref PubMed Scopus (108) Google Scholar 39Haythornthwaite JA Menefee LA Quatrano-Piacentini Papagallo M Outcome of chronic opioid therapy for non-cancer pain.J Pain Symptom Manage. 1998; 15: 185-193Abstract Full Text Full Text PDF PubMed Scopus (125) Google Scholar 47Jamieson RN Raymond SA Slawsby EA Nedeljkovic SS Katz NP Opioid therapy for chronic noncancer back pain. A randomised prospective study.Spine. 1998; 23: 2591-2600Crossref PubMed Scopus (284) Google Scholar 60Moulin DE Iezzi A Amireh R Sharpe WKJ Boyd D Mersky H Randomised trial of oral morphine for chronic non-cancer pain.Lancet. 1996; 347: 143-147Abstract PubMed Scopus (379) Google Scholar 98Watson CP Babul N A randomized trial in postherpetic neuralgia.Neurology. 1998; 50: 1837-1841Crossref PubMed Google Scholar A reduction in pain intensity was accompanied by an improvement in the overall Pain Disability index (PDI) score and in most of the PDI sub-scales in one study comparing controlled-release codeine with placebo.2Arkinstall W Sandler A Goughnour B Babul N Harsanyi Z Darke A Efficacy of controlled-release codeine in chronic non-malignant pain: a randomized, placebo-controlled clinical trial.Pain. 1995; 62: 169-178Abstract Full Text PDF PubMed Scopus (165) Google Scholar In a study of elderly patients with post-herpetic neuralgia, oxycodone reduced pain, allodynia, and disability scores compared with placebo.98Watson CP Babul N A randomized trial in postherpetic neuralgia.Neurology. 1998; 50: 1837-1841Crossref PubMed Google Scholar In contrast, although Moulin reported analgesic benefit from morphine, patients did not show any improvement in physical or psychological functioning.60Moulin DE Iezzi A Amireh R Sharpe WKJ Boyd D Mersky H Randomised trial of oral morphine for chronic non-cancer pain.Lancet. 1996; 347: 143-147Abstract PubMed Scopus (379) Google Scholar Jamieson reported alleviation of pain and mood improvement, but no increase in activity levels in patients with chronic back pain. In this study, patients showed a preference for the short-acting opioid (oxycodone) as compared with the sustained-release morphine. They rated oxycodone as more helpful and reported being more confident in the knowledge that they had access to short-acting opioids should the pain flare up. Patients who varied their opioid dose from week to week reported less pain and better mood than those who did not. This runs counter to previous argument that taking opioid on a pain-contingent basis increases the likelihood of reinforcement of pain behaviour and dosage increase.47Jamieson RN Raymond SA Slawsby EA Nedeljkovic SS Katz NP Opioid therapy for chronic noncancer back pain. A randomised prospective study.Spine. 1998; 23: 2591-2600Crossref PubMed Scopus (284) Google Scholar From clinical experience with the cancer pain population, the chronic non-cancer population and in the ‘methadone-maintained’ population, it would appear that long-term opioid therapy is not associated with major organ toxicity.51Kreek MJ Medical safety and side effects of methadone in tolerant individuals.JAMA. 1973; 223: 665-668Crossref PubMed Scopus (218) Google Scholar 89Taub A Opioid analgesics in the treatment of chronic intractable pain of non-neoplastic origin.in: Kitahata LM Collins JG Narcotic Analgesics in Anesthesiology. Williams & Wilkins, Baltimore/London1982: 199-208Google Scholar There is an increasing body of evidence, obtained both from in vitro and in vivo studies in animals and humans, showing that exogenous opioids are able to suppress a variety of immunological responses.15Carr DJ Rogers TJ Weber RJ The relevance of opioids and opioid receptors on immunocompetence and immune homeostasis.Proc Soc Exp Biol Med. 1996; 213: 248-257Crossref PubMed Scopus (109) Google Scholar 28Eisenstein TK Hilburger ME Opioid modulation of immune responses: effects on phagocyte and lymphoid cell populations.J Neuroimmunol. 1998; 83: 36-44Abstract Full Text Full Text PDF PubMed Scopus (230) Google Scholar 61Nelson CJ Dykstra LA Lysle DT Comparison of the time course of morphine’s analgesic and immunologic effects.Anesth Analg. 1997; 85: 620-626PubMed Google Scholar 75Rouveix B Opiates and immune function. Consequences on infectious diseases with special references for AIDS.Therapie. 1992; 47: 503-512PubMed Google Scholar In humans, most data are based on the evaluation of immune function in i.v. heroin users and methadone-maintained patients (MMPs).62Novick DM Ochshorn M Ghali V Croxson TS Mercer WD Chiorazzi N Kreek MJ Natural killer cell activity and lymphocyte subsets in parenteral heroin abusers and long-term methadone maintenance patients.J Pharmacol Exp Ther. 1989; 250: 606-610PubMed Google Scholar 74Risdahl JM Khanna KV Peterson PK Molitor TW Opiates and infection.J Neuroimmunol. 1998; 83: 4-18Abstract Full Text Full Text PDF PubMed Scopus (137) Google Scholar However, effects have also been shown in human volunteers99Yeager MP Colacchio TA Yu CT Hildebrandt L Howell AL Weiss J Guyre PM Morphine inhibits spontaneous and cytokine-enhanced natural killer cell cytotoxicity in volunteers.Anesthesiology. 1995; 83: 500-508Crossref PubMed Scopus (264) Google Scholar and post-operative patients.77Sacerdote P Bianchi M Gaspani L Manfredi B Maucione A Terno G Ammatuna M Panerai A The effects of tramadol and morphine on immune responses and pain after surgery in cancer patients.Anesth Analg. 2000; 90: 1411-1414Crossref PubMed Scopus (292) Google Scholar A recent study investigated immune responses in 10 patients with pain (seven non-malignant and three because of cancer) before and after treatment with sustained-release morphine and compared them with eight healthy control subjects not taking morphine. The cellular immune responses did not initially differ between patients and controls and did not show any significant changes during treatment. Immunoglobulin (Ig) production was reduced in the chronic pain patients before morphine was commenced and further reduced by morphine therapy. The clinical impact on the immune system as a whole of this suppression of humoral response remains to be elucidated.63Palm S Lehzen S Mignat C Steinmann J Leimenstoll G Maier C Does prolonged oral treatment with sustained-release morphine tablets alter immune function?.Anesth Analg. 1998; 86: 166-172PubMed Google Scholar It has been suggested that chronic opioid administration can induce a state of immune tolerance with normal resistance to viral infections.12Bryant HU Bernton EW Holaday JW Morphine-induced immunomodulation in mice: temporal relationships.J Pharmacol Exp Ther. 1988; 245: 913-920PubMed Google Scholar 75Rouveix B Opiates and immune function. Consequences on infectious diseases with special references for AIDS.Therapie. 1992; 47: 503-512PubMed Google Scholar It is apparent that this is an area in which a better understanding of these intera" @default.
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• W2155442308 date "2001-07-01" @default.
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• W2155442308 title "Chronic opioid therapy for non-cancer pain" @default.
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