Opioids in the treatment of chronic pain: legal framework and therapeutic indications and limitations.
The most important message that physicians must communicate to persons with chronic pain is that, currently, no medication exists that will take away more than 30% of the pain they experience. Chronic pain is a chronic disease and, like diabetes or hypertension, requires chronic concessions and lifestyle modifications. In controlled trials of short duration and small sample size with highly selected patients, patients sustaining moderate-to-severe pain still experience moderate pain even on opioid medication. Adverse drug effects are predictable and common, and, in fact, long-term compliance with opioids is low owing to side effects. Screening for substance abuse by history taking, observing behavior, obtaining old medical records,and using UDS in patients before initiating opioid therapy is important to identify patients with comorbid addictive disease who require coincident or antecedent treatment. Familiarity with federal and state controlled substance legislation and state health care provider and pain treatment acts is a mundane but essential educational endeavor for all physicians prescribing opioids. If physicians educate their patients with chronic pain about the limited efficacy of the medications, patients' expectations for drug treatment can be more realistic.