What Role for Short-Acting Opioids in the Control of Chronic Nonmalignant Pain?

As a physician who specializes in pain management, I read with interest thearticle on chronic nonmalignant pain by Drs Atli and Loeser (CONSULTANT,November 2004, page 1693). Although the article was otherwise extremely informative,I was troubled by the authors' failure to clarify the meaning of"breakthrough pain" in a nonmalignant setting and by their advocacy of theuse of short-acting opioids to treat such pain.Breakthrough pain is a concept that has facilitated adequate treatment ofacute pain (such as postsurgical pain) and cancer pain. There is no basis, inmy opinion (and that of many others who regularly prescribe opioids), for itsextrapolation to a nonmalignant setting. Short-acting opioids are among themost seductive drugs that can be prescribed. Moreover, their daily use teachespatients to focus on their pain and encourages pill-taking behaviors. As the authorscorrectly point out elsewhere in the article, the focus of treatment shouldbe on increasing the level of functioning rather than on relief of pain per se.While a student in Dr Loeser's excellent pain program at the University ofWashington, I was taught to prescribe opioids for nonmalignant pain--if atall--on a time-contingent basis only, not on a pain-contingent basis. Ratherthan have patients take short-acting opioids, they were to be encouraged to useother modalities, such as those mentioned in the article.I would caution readers against using short-acting opioids for nonmalignantpain. The most difficult patients I have had over the years have beenthose who were taking high dosages of short-acting opioids when they werereferred to me.-- Ashok Jayaram, MD
   Portland, Ore
As we indicated in our article, short-acting opioids should be usedwith caution in patients with chronic pain and should not be themainstay of therapy. However, we do see some patients whosepain is exacerbated by activity, position, or other factors, and forwhom it is reasonable to prescribe occasional, supplementalshort-acting opioids. In our article, we tried to emphasize the roles of nonopioidmedications and other therapeutic modalities in the treatment ofnonmalignant chronic pain. We agree that short-acting opioids, especially inthe absence of nonpharmacologic treatment, are often deleterious to patientswith chronic pain.-- John D. Loeser, MD
   Professor
   Departments of Neurological Surgery and Anesthesiology
-- Aysel Atli, MD
   Fellow
   Department of Anesthesiology
   University of Washington School of Medicine
   Seattle