Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

378 IV. SPECIAL POPULATIONSapproaches that may be combined in such a strategy (Table 17.3). If primarytherapy against an identified etiology is possible, and appropriate, this should beconsidered as symptomatic treatments are offered.Analgesic PharmacotherapyDrugs used to treat chronic pain can be divided in three categories: nonopioidanalgesics (acetaminophen and the nonsteroidal anti-inflammatorydrugs [NSAIDs]), adjuvant analgesics, and the opioids. Opioid pharmacotherapyis most relevant for the current discussion.OPIOID ANALGESICSPain specialists now consider long-term opioid therapy to be a major element inthe approach to chronic pain, and specialists in pain medicine and in addictionmedicine have begun to discuss the role of this approach in patients with historiesof drug abuse or addiction. During the past few years, there has been a dramaticincrease in the willingness of primary care physicians to consider longtermtreatment for selected patients. As a result, overall access to these drugshas risen substantially. Concurrently, indicators of abuse and diversion havealso tracked upward. Warnings raised by regulators and law enforcement havebegun to increase concerns on the part of prescribers about the possibility ofinvestigation and even sanction for prescribing opioids. This concern has beena constant in the United States for many decades and has been viewed by painspecialists as a significant barrier to appropriate opioid use.The call for a more balanced approach to the role of opioid drugs derivesfrom this present tension. Whether from the larger perspective of society orhealth care, or the microperspective of the individual clinician, the appropriateparadigm now emphasizes the need for a more nuanced perspective. This perspectiveaccepts the legitimate role of opioid therapy in the management ofappropriate patients with chronic pain (and the likelihood that prescribingneeds to be increased to address the problem of undertreated pain) and concurrentlyrecognizes the need to minimize the risk of adverse outcomes associatedwith chemical dependence. This paradigm now forms the foundation for themanagement principles that guide opioid therapy (Table 17.4).Patient Selection. It is no longer appropriate to peremptorily reject the useof opioid drugs solely on the basis of pain syndrome or the psychiatric conditionof the patient. Given the existing data and a large clinical experience, the mostreasonable posture is to consider a trial of opioid therapy for any patient withchronic or frequently recurrent pain of moderate to severe intensity, and thento base the decision to proceed or not on the responses to the following questions: