COMMENTARY

The Pitfalls of Opioids for Chronic Nonmalignant Pain of Central Origin

Stephen G. Gelfand, MD

Disclosures

February 25, 2002

Effects of Opioid Dependence

Self-efficacy and dependence on drugs for pain are opposite therapeutic objectives. Although certain medications such as low-dose tricyclic antidepressants for improved sleep and selective serotonin reuptake inhibitors (SSRIs) for depression and/or persistent pain are beneficial in selected patients with fibromyalgia, conventional drug management by itself has not been shown to improve outcomes in this disorder.[21,22] The same conclusion also applies to chronic low back pain not caused by specific structural lesions. Both conditions frequently have multiple psychosocial and cognitive variables unique to each individual that need to be recognized and treated as part of a multidisciplinary treatment program including self-management techniques. Disregarding these factors, which are essential in the origin and amplification of symptoms, predisposes the patient to polypharmacy, drug dependence, and a dysfunctional state in which each symptom is medicalized.

One of the most common reasons for patient visits today is the large range and severity of multiple unexplained symptoms, including pain, which are associated with stressful life events, psychological distress, depression, and anxiety disorders.[23] Fibromyalgia syndrome should be viewed and managed in this broader context, rather than as a discrete disease requiring medications (including opioids) as principal therapy. Recognition that a number of these patients would rather have a "physical disease" than confront the effects of stressful past or present life circumstances may be helpful in their overall evaluation process. Furthermore, this comprehensive approach considers the chronic muscle pain of fibromyalgia syndrome to be just one of many symptoms that can be generated by chronic tension and stress originating from biopsychosocial factors, rather than as a distinct disease in the traditional biomedical sense.[12]

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