Chronic opioids for chronic low back pain--solution or problem?

Abstract

The article by Brown et al does not provide data to justify long-term opioid use but does suggest a treatment option for the many patients who have chronic back pain and who want the help that our medical delivery system often does not provide. Having worked in a tertiary referral pain clinic that serves many low back pain patients who have demonstrated the ineffectiveness of chronic opiate therapy, I am strongly ambivalent about recommending prescribing ongoing opioiod therapy for chronic pain patients. The caveats about prescribing opioids for such patients are most appropriate (i.e., do not prescribe opioids for those who have a history of problems with opioid therapy or for whom increased intake is associated with decreased function); however, for patients who do not display these problems (and there could be many out there), I am sympathetic with the sentiments expressed by Brown et al. A trial of these drugs might be warranted if all else fails and continued therapy with opioids seems justified, but only with zealous attention to monitoring function and therapeutic compliance, as outlined by the authors. With regard to the doses needed for control, the method of opioid administration might be important, that is, whether it is in tablets or in a masking vehicle. In this day of open dialogue, it is not fashionable to blind the patient to the drug or dose, but I believe blinding has a place in the care of a particular group of patients whose symptom (pain) can vary considerably with time. I have found that most chronic pain patients rarely, if ever, reduce their analgesic intake in better times, but an attentive physician can if masking vehicles are used. Thus the physician can limit the amount of drug consumed long term. In my personal experiences with comparable chronic nonmalignant pain patients (albeit in different hemispheres), the average opioid maintenance (methadone) dosage was halved by prescribing the drug in a masking vehicle rather than as a tablet. If pain complaints are reduced and if function is improved according to the record (eg, patient is working) and the relatives' report, and if you, the prescribing physician, are happy, then a long-term regimen of opioid therapy is probably fine. Further controlled trials are needed to see whether this therapy works, and if so, what are the optimal agent(s) and dosages, what is optimal monitoring, and most important of all, who is the optimal patient who might derive not only analgesia but also functional benefit rather than compromise from this therapy. If we cannot make patients better, we must not make them worse.