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The middle way: a practical approach to prescribing opioids for chronic pain

Nature Clinical Practice Neurology volume 2, pages 580–581 (2006)Cite this article

Chronic pain exacts an enormous physical, emotional and financial toll on society, with prevalence rates reported in different reviews ranging from 10% to 50%.1 In recent years, a paradigm shift has occurred in the approach to treating chronic nonmalignant pain. This shift has generated an unprecedented controversy reverberating throughout medical, judicial, health-policy and patient-advocate circles. Ironically, this philosophical change is not attributable to the advent of a new class of analgesics or an innovative procedure to relieve pain. The controversy revolves around opioids, the medicinal use of which possibly dates as far back as the 5th millennium BC by the ancient Sumerians and Egyptians.

In the 1980s, the role of opioids in the management of chronic noncancer pain was fervently debated. Opioids were considered inappropriate for chronic pain management owing to concerns about adverse effects, tolerance, dependence and addiction. In the subsequent decades, several circumstances shifted the scale in the opposite direction. First, controlled trials of opioids reported positive outcomes in chronic nonmalignant and neuropathic pain states, conditions previously thought to be resistant to opioids.2 Second, case reports indicated a low incidence of addiction in patients with no history of substance abuse who received opioids for chronic pain.3 Last, health-care professionals, including physicians, became subject to civil and professional action for failing to treat pain appropriately. In a highly publicized case in 2001, a California jury awarded a US$1.5 million verdict against a physician for failing to prescribe adequate pain medications.

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  1. Associate Professor and SN Raja is Professor in the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA

    Steven P Cohen & Srinivasa N Raja

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  1. Steven P Cohen
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  2. Srinivasa N Raja
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Correspondence to Srinivasa N Raja.

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The authors declare no competing financial interests.

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Cohen, S., Raja, S. The middle way: a practical approach to prescribing opioids for chronic pain. Nat Rev Neurol 2, 580–581 (2006). https://doi.org/10.1038/ncpneuro0342

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