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Am Fam Physician. 1999;59(2):467-468

The use of opioids in the treatment of chronic musculoskeletal pain is controversial. Concerns about efficacy, toxicity and the development of tolerance, dependence, addiction or abuse have been raised. Physicians may also be concerned about scrutiny by regulatory agencies when prescribing long-term opioid medications. Recent studies of the use of opioids in cancer patients suggest that there is a place for these medications in the treatment of chronic pain. Ytterberg and associates examined efficacy, toxicity, tolerance, addiction and abuse behaviors in patients who received opioid therapy for pain associated with chronic rheumatic disease.

Patients at a rheumatology clinic who had received at least one prescription for opioid therapy were enrolled in the study. Data were obtained from computerized pharmacy records, medical record reviews and patient interviews. Patients who did not receive opioids served as the control group. The 290 patients who received opioids were divided into two groups: long-term users (137 patients) and short-term users (153 patients). Long-term use was defined as opioid therapy lasting for at least three consecutive months; short-term use was defined as opioid therapy lasting fewer than three consecutive months. Dosage escalation was defined as an increase of two or more equivalents of 30 mg of codeine per day. Patients were asked to rate their pain on a scale of zero to 10, before and after a dose of their pain medication.

No significant demographic differences were noted between patients in the short-term, long-term or control groups. Opioid use in both the long-term and short-term groups had a significant impact on pain reduction. Over 85 percent of patients in these groups experienced reduction of pain severity of at least 30 percent. Thirty-eight percent of these patients reported side effects from opioid use, but very few patients stopped taking the opioid because of these side effects. No significant escalation of opioid dosage over time was reported in the long-term treatment group. Some patients did escalate their dosage, but 97 percent of the time this escalation was related to an increase in the severity of their pain. Only four patients were found to have developed tolerance to the drug and behaviors consistent with abuse. Seventy-three of the 133 patients receiving long-term therapy reported not taking medication on days with less pain because they were afraid of becoming addicted or dependent.

The authors conclude that their findings support the use of both long-term and short-term use of opioids in the treatment of musculoskeletal pain. Concerns about tolerance and escalation of opioid dosage were not supported by the study. Most patients participating in the study used opioids in an appropriate manner, escalating the dosage when needed and then returning to their baseline dosage. The authors state that it is no longer appropriate to withhold opioid treatment from patients with chronic pain from rheumatic disease because of doubts or concerns about opioid efficacy, tolerance, toxicity and abuse or addiction.

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Copyright © 1999 by the American Academy of Family Physicians.

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