Chronic opiate therapy incurs some concerns, so we do not consider this therapy lightly, but, when indicated, we will pursue this route to a stable maintenance status. Considerable controversy exists about the use of opioid analgesics for chronic non-cancer pain. Opioids have been accepted as appropriate treatment for acute pain and for pain associated with cancer. Many physicians and health care professionals are reluctant, however, to support the use of opioid medication for patients with chronic pain because of concerns about efficacy, adverse effects, tolerance, and addiction. Studies performed in pain clinics suggest that some patients become psychologically dependent after long-term opioid use. However, some clinicians and researchers have argued that there is a role for chronic opioid therapy for non-cancer pain. They cite the relatively low incidence of abuse and addiction among the affected patients and report that tolerance apparently does not develop in patients with stable pain pathophysiology. They suggest that the potential for increased function and improved quality of life are the mainstay of therapy. Investigators have also suggested that chronic opioid therapy may decrease the cost of rehabilitation programs for pain patients while improving outcome.

The need for studies that empirically address this controversial topic of opioid treatment for chronic non-cancer pain has been noted repeatedly in the pain literature. A recent study completed at Brigham and Women's Hospital (Jamison et al., 1998) examined the long-term efficacy of chronic opioid therapy in patients with persistent back pain unrelated to cancer. The results of this study suggest that opioid therapy alleviates pain and improves mood but does not consistently affect activity level. Chronic opioid therapy seems to benefit some patients without significant risk of abuse. Further study is needed to identify those qualities, which predict a positive outcome of chronic opioid therapy. ISM provides for a comprehensive assessment of the risk and benefits of increased function with regard to consultation on pharmacotherapy.