• Michael K Nicholas, Allan R Molloy, and Charles Brooker.
• University of Sydney Pain Management and Research Centre, Royal North Shore Hospital, St. Leonards, Australia. miken@med.usyd.edu.au
• Clin J Pain. 2006 Feb 1; 22 (2): 137-46.

ObjectiveDespite the growing use of opioids for persisting noncancer pain, evidence for their effectiveness is limited, especially in relation to functional outcomes. Guidelines have been developed for prescribers, but their utility is untested. This review examines the use of opioids in this population from a biopsychosocial perspective and makes a number of recommendations.Data SourcesPublished comparison studies and reviews of oral opioids in chronic noncancer pain, as well as 5 published guidelines for the prescription of opioids and systematic reviews of cognitive-behavioral pain management programs.MethodsOutcomes of the opioid comparison studies were reviewed and compared to those achieved by pain management programs.ConclusionsThe available evidence indicates that by themselves, oral opioids generally achieve only modest reductions in pain levels in patients with chronic noncancer pain. Functional outcomes are inconsistent across studies. There are questions about the timing of their use and patient selection. There are risks in trials of opioids only after other conservative interventions have been tried unsuccessfully. Also, in some patients, ongoing use of opioids risks repeated over-doing of pain-generating activities and reinforcing escape/avoidance responses that promote disability. These risks may be lessened by assessment of current use of pain self-management strategies among potential candidates for opioids. This offers advantages in promoting collaborative management of persisting pain as well as better pain and functional outcomes. In this view, opioids may be considered as one possible element of a management plan rather than the primary treatment.

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