THIS IS WHAT THE NATIONAL INSTITUTE HAS TO SAY ABOUT THE USE OF NARCOTICS IN
CHRONIC PAIN PATIENTS:

Pain Medications
018

Pain is the most common reason people visit a doctor. When treating pain,
physicians have long wrestled with a dilemma: How can a doctor relieve a
patient's suffering while avoiding the potential for that patient to become
{*filter*}ed to a powerful, opiate pain medication?

Today, the medical profession has concluded that many doctors underprescribe
powerful painkillers because they overestimate the potential for patients to
become {*filter*}ed to these painkillers, which include opiates (from {*filter*}) such
as morphine and codeine, and substances that are structurally related to
morphine. The term "opioids" is used to describe the entire class (both
synthetic and natural) of chemicals structurally similar to morphine. Although
these {*filter*} carry an extreme risk of {*filter*}ion for many people, many physicians
are not aware that these {*filter*} are rarely abused when used for medicinal
purposes.

When doctors limit pain medication, thousands of patients suffer needlessly,
according to a number of studies. This quandary over the prescription of
powerful pain relievers continues while investigators search for new ways to
control pain. NIDA-funded researchers are spearheading the exploration for new
painkillers that are effective but non{*filter*}ing.

{*filter*}, the bitter dried juice of the {*filter*} poppy, has been used for centuries
to relieve pain. {*filter*}'s analgesic properties come from morphine, {*filter*}'s major
active component.

In the 1970s and 1980s, researchers discovered morphine-like substances that
occur naturally in the body, the endogenous opioid peptides.

However, the debilitating side effects that opiate medications can produce,
such as nausea, sedation, confusion, and constipation, limit their
effectiveness and contribute to the need for alternative analgesics.

NIDA-supported researchers are addressing this need through a number of
experimental approaches. These include:

Developing opioid compounds, syn thetic derivatives of opiates, that promote
pain relief without producing the euphoria, or "high," that can lead to
{*filter*}ion
Developing "promoter compounds" that enhance the pain-relieving effects of
opioids so that smaller doses can be used
Developing nonopioid analgesics that function through different pain-relief
processes and presumably will not produce the negative side effects of opioids
Years of research have uncovered three categories of opioids: agonists, such as
Demerol and methadone, that mimic the effects of endogenous opioids;
antagonists, such as naloxone, that block certain effects of opioids; and mixed
agonist-antagonist opioid agents, such as buprenorphine and nalbuphine, that
both activate and block specific opioid effects. These partial
agonists-buprenorphine and nalbuphine- minimize the agonists' negative side
effects, including sedation, respiratory problems, and abuse potential, while
relieving pain.

Opiates, including morphine and codeine, and synthetic opioids, such as Demerol
and fentanyl, work by mimicking the endogenous opioid peptides, pain-relieving
chemicals produced in the body. These peptides bind chemically to opiate
receptors, activating pain- relieving systems in the brain and spinal cord. But
opioids can cause undesirable side effects such as nausea, sedation, confusion,
and constipation. With prolonged use of opiates and opioids, individuals become
tolerant to the {*filter*}, require larger doses, and can become physically
dependent on the {*filter*}.

In recent years, research has shown that doctors' fears that patients will
become {*filter*}ed to pain medication, known as "opiophobia," are largely
unfounded. Studies indicate that most patients who receive opioids for pain,
even those undergoing long-term therapy, do not become {*filter*}ed to these {*filter*}.
The very few patients who develop rapid and marked tolerance and {*filter*}ion to
opioids are usually those who have a history of psychological problems or prior
substance abuse.

One study found that only four out of more than 12,000 patients who were given
opioids for acute pain actually became {*filter*}ed to the {*filter*}. Even long-term
therapy has limited potential for {*filter*}ion. In a study of 38 chronic pain
patients, most of whom received opioids for 4 to 7 years, only 2 patients
actually became {*filter*}ed, and both had a history of drug abuse.

The problem of underprescription of opiates and opioids and the accompanying
needless suffering for millions of patients has prompted official reaction. In
1992 the Federal Agency for Health Care Policy and Research issued guidelines
for the treatment of pain. The recommendations encourage health professionals
to ignore myths about {*filter*}ion to pain medications and to cease groundless
restrictions on the dispensing of opioid pain relievers. The guidelines also
recommend greater use of intravenous drug "pumps," which allow nurses or
patients themselves to control the timing and dosage of the drug being taken.
Following the guidelines, the agency said, would not only relieve unnecessary
suffering, but would speed patients' recovery and reduce hospital stays and
costs.

 U.S. Department of Health and Human Services National Institutes of Health.
Send comments and questions to NIDA Infofax, P.O. Box 30652, Bethesda, MD.
20824-0652. This material may be used or reproduced withouth permission from
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