Chronic non-cancer pain and opioid dependence.

There are four main questions to address on the subject of chronic non-cancer pain and opioid addiction. Are opioids effective in the treatment of such pain? If so, do the risks of iatrogenic addiction outweigh the benefits? To what extent do patients with primary opioid addiction experience chronic pain? How should this pain be treated? We review the subject from a UK perspective. Most of the published work comes from the USA, where addiction tends to be viewed primarily as a neurobiological disease or disorder, albeit one that can be influenced by environmental factors.^_1 UK workers are less inclined to privilege the biological over the psychosocial—readier to accept that people can make heavy use of drugs without being addicted, that the heavy use of drugs can be a choice rather than 'loss of control', and that many people can modify their drug consumption without help.^_2 Indeed, there are those who see addicts' descriptions of their 'compulsive behaviours' as an artifact of the social and legal prohibitions on the use of drugs (i.e. that the claim 'I only take drugs because I am addicted' is merely a post-hoc rationalization).^_3 Even in the treatment of pain, the prescription of opioid analgesics has waxed and waned according to the fashion of the moment.The term addiction is ubiquitous in the published work but is no longer found in either of the contemporary diagnostic manuals, the Diagnostic and Statistical Manual of Mental Disorders (DSM)^_4 or the International Classification of Diseases (ICD).^_5 We use it here because it retains ideas about 'loss of control' and chaotic drug use despite adverse physical, mental and social consequences.