Opiophobia, Opiophilia, Opioagnosia

When you're on a limb, how far out do you go?The literature is replete with reviews, editorials, and opinion papers regarding the chronic use of opioids for non-malignant pain. Despite these, and despite a decade and a half of discussion, investigation, and clinical use, there continues to be polarization of opinion as well as practice. In a 1997 editorial, Dr. Peter Wilson noted, “There appears to be little hope for a rational outcome as the discussion is dominated by zealots at one extreme and nihilists at the other”[1]. Fortunately, this statement seems somewhat less true now than at the time he wrote it; however, there continue to be those who “just say no,” and those for whom opioids are the answer. Our situation seems to uphold the aphorism that the heat of argument is inversely proportional to the persuasiveness of the data, though some of the current divergence of opinion clearly results from incomplete dissemination of the available data.The situation regarding opioid treatment of acute and cancer pain is much better than that regarding chronic pain treatment (at least in the United States). Occasionally one still hears of a physician who withholds opioids from terminal patients or from orthopedic surgery cases, but those who discuss it do so in the tones of incredulity generally reserved for those who harbor beliefs in phlogiston. The recent initiatives by JCAHO and the Veterans Administration should help to relegate such attitudes to the past.There has been a severe failure to adequately treat acute and malignant pain. While this failure has been ascribed to “opiophobia,” philosophical opposition to use of adequate opioids in such situations was only part of the problem. Sadly, much suffering resulted from a simple failure of health professionals to notice. Adopting pain as a 5th vital …