The role of opioids in managing chronic non-cancer pain

The use of opioids for the treatment of chronic non-cancer pain has become more widespread recently. Available data support the short-term use of opioids in clearly defined nociceptive and neuropathic pain states. Their use in 'pathological' pain states without a clear diagnosis, such as chronic low back pain, is more contentious. A decision to initiate opioid treatment in these conditions requires careful consideration of benefits and risks; the latter include not only commonly considered adverse effects such as constipation, but also opioid-induced hyperalgesia, abuse, addiction and diversion. Ideally, treatment goals should not only be relief of pain, but also improvement of function. Opioid treatment of chronic non-cancer pain requires informed consent by, and preferably a treatment contract with, the patient. Treatment should be initiated by a trial period with defined endpoints using slow-release or transdermal opioids. Ongoing management of the patient requires ideally a multi-disciplinary setting. Treatment should not be regarded as life-long and can be discontinued by tapering the dose.