Opioid maintenance therapy should be considered only after all other reasonable attempts at analgesia have failed and when persistent pain is a significant impediment to improved function.

Functional improvement should be emphasized as the most important goal of therapy, and the patient should be encouraged at every step to capitalize on progress in analgesia by gains in physical activity or social interaction. However, it should be recognized that partial analgesia with relatively little functional gain is the more likely outcome.

A substance-abuse history should be viewed as a relative contraindication to opioid maintenance therapy. No other factor is likely to predict treatment failure or the development of management problems.

A single committed physician must take primary responsibility for the management of therapy. In all reported cases of successful opioid maintenance therapy, the close and concerned involvement of such an individual was available; indeed, the strength of this relationship is one potential explanation for the success of treatment.

Since many patients begun on chronic opioids obtain partial or inadequate analgesia, the physician must be willing to stop ineffective therapy or escalation of doses when clinical judgment indicates diminishing returns. These interventions, occurring at a time the patient may be first experiencing some degree of analgesia, are difficult. They are simplified by a therapeutic alliance based on the physician’s sensitive understanding of the patient’s position and the patient’s perception that decisions are taken solely in his or her best interest.

• Russell K. Portenoy, MD

From the chapter “Opioids in Nonmalignant Pain,” by Russell K. Portenoy, MD, Psychiatrist, Pain Specialist and Professor, in the textbook CURRENT THERAPY OF PAIN, published in 1989. (Reproduced with emphasis added.)

Reference: Current Therapy of Pain

Publisher: Mosby Inc (January 1, 1989)

ISBN-10: 1550090089

ISBN-13: 978-1550090086

 

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