ROCHESTER, Minn. -- Opioid analgesics (opioids), powerful pain relievers whose use has been hotly debated in the medical community, should be prescribed for some patients with chronic lower back pain, according to a Mayo Clinic article published in the September 2002 issue of Pain Medicine, http://www.blackwellscience.com/journals/pain. After reviewing all available studies of opioid use for this condition, the author recommends that physicians and their patients at least consider opioids for the treatment of chronic, nonmalignant pain, including musculoskeletal pain and chronic lower back pain, before a patient undergoes surgery.

"Although this is somewhat controversial in that the majority of physicians still have prejudices against the use of opioid analgesics for chronic pain, there is a place for their carefully considered and closely monitored use in patients with low back pain," says J. D. Bartleson, M.D., Mayo Clinic neurologist and lead author of the paper.

Opioids are pain relievers derived from or resembling those derived from the opium plant. Well-known examples of this class of medications include morphine, oxycodone and fentanyl. The use of opioids is complicated for patients and physicians due to controversy over misuse and potential drug dependence.

"Opioids are some of the most underused drugs around because of the possibility of abuse," says Mike Joyner, M.D., Mayo Clinic anesthesiologist. "Opioids are wonderful drugs, but because of the abuse problem and moral overlay, it's hard to get a straight answer. This is because of irresponsible use by a limited number of people."

"Opioids can be a "lifesaver' for patients with severe pain," continues Dr. Joyner. "For people with chronic pain, opioids can be like letting them out of jail."

Dr. Bartleson's article reports a dearth of randomized, controlled trials of opioid analgesic therapy for chronic lower back pain, the most common chronic pain syndrome in the United States. The available data from all studies of chronic lower back pain patients, however, indicate that opioids are useful for pain relief.

Though their effectiveness in pain relief has not been widely questioned, the prescription of these medications for patients who do not have cancer has remained contentious in the medical community.

This study addresses some of the following major objections that have been raised related to using opioids for pain relief:

* Risk of side effects: In published studies on opioid analgesics, opioids are associated with some moderate side effects, but not with long-term adverse effects.

* Development of tolerance and need to increase dosage over time: Available studies indicate that opioid dosage remains fairly stable over time and benefit is maintained; however, many of the published studies are of relatively short duration.

* Risk of drug dependence and withdrawal if the drug is stopped or dosage reduced: Existing studies indicate a low risk of drug dependence and withdrawal.

Additionally, the studies point to a preference for longer-acting versus shorter-acting opioids for persistent lower back pain relief, and they indicate a vital need to carefully select which patients to treat with opioids and closely monitor patient progress.

Even the author of the paper indicates that while his research has convinced him that opioids have a place in pain medicine, he takes a cautious approach with his own patients.

"Although I am now a "believer,' I still don't treat many patients with opioids," says Dr. Bartleson.

Both Dr. Bartleson and Dr. Joyner call for additional objective evidence regarding opioids for chronic lower back pain in the form of controlled, blinded, long-duration studies of specific opioids.

"This study highlights the need for well-done studies on the treatment of back pain," says Dr. Joyner. "The cost of back pain to our society -- in numbers of days of missed work, etcetera -- is huge."

---Pain Medicine