Commonsense Opioid-Risk Management in Chronic Noncancer Pain: A Clinician’s Perspective

Chronic noncancer pain (CNP) is a serious and likely undertreated public health problem. In a 2005 survey, 19% of US adults reported chronic pain and 34% reported recurrent pain [Kuehn 2007]. The annual costs of pain-related healthcare, litigation, and compensation are estimated at $100 billion in the United States alone [Sinatra 2006]. While opioids have been a mainstay in the treatment of acute pain, the role of opioids in treating chronic pain is less well defined and overshadowed by persistent concerns of misuse, abuse, and addiction. Fortunately, during the past 20 years, there have been major advances in clarifying these issues. Publication of the World Health Organization (WHO) Analgesic Stepladder in 1986 provided a tool for guiding nonspecialists in the logical use of opioids for cancer pain [Ballantyne 2003]. In the early 1990s, clinicians began to acknowledge that opioids also had a genuine role in the treatment of CNP [Portenoy 1990]. The Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) placed additional emphasis on the appropriate treatment of pain through its publication of pain management standards in 1999 [Dahl et al. 2000].

Since then, key organizations have developed consensus statements to guide providers in prescribing opioids for CNP [Atluri et al. 2003; CPSO 2000; VA/DoD 2003]. Many states also have responded by adopting “Intractable Pain Treatment Acts” that specifically allow opioids to be prescribed for CNP and reduce the fear of Board actions against practitioners who prescribe them [IPTA 2006].