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While the therapeutic benefits of opioids have been appreciated for millennia, so
have their addicting effects. Physicians have long understood that prolonged opioid
treatment is accompanied by addiction risk. Fear of addiction is the main reason
for “opiophobia,” and the main reason that opioid treatment was not commonly
extended to patients with chronic pain until late in the twentieth century. History
has also taught that opioid addiction becomes a societal problem only when opioids
reach a critical point in availability and usage, as was observed when opium
cultivation and usage spread from the middle east to the far east and then on to
the western world. The clear message is that not all users become addicted, but a
certain proportion does, and so the more the usage is there, the more the addiction
will become a problem. Why then did twentieth century physicians feel confident
that addiction would not be a problem if opioid therapy was extended to chronic
pain patients? This perception was largely based on the greater understanding
of opioid mechanisms brought about by the discovery of endogenous opioid systems,
the confidence that opioids have unique analgesic properties, and the observation
that when treating severe pain, euphoria and other side effects seem muted.
Yet the actual experience has been that the addiction does indeed arise during opioid
treatment of chronic pain, at a rate that is not dissimilar to that seen in the general
population (5–30% of those exposed) (1). Should this deter opioid treatment of
chronic pain? The question is, should all patients be denied opioids for the treatment
of severe chronic pain because there will be a poor outcome in some? Most
people would say no.We can do better than this because we are beginning to gain a
depth of knowledge about how and why opioids produce addiction and how addiction
can be avoided, and we can use this knowledge to structure opioid treatment
of pain so that addiction risk is minimized.

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