Why Is Chronic Opioid Therapy Not Working for My Patient’s Pain?

Abstract This chapter suggests an approach to managing the complex effects of chronic opioid therapy (COT). Opioids generate ambiguity, conflict, and anxiety for both patients and clinicians deciding on their chronic use for chronic sickle cell disease (SCD) pain. While COT can be effective for chronic non-cancer pain like SCD pain, the short-term benefits of opioids often may not be sustained long-term. COT often fails to produce clinically significant benefit or may not outperform other interventions. COT is qualitatively more risky than other pharmacological interventions for pain because opioids are associated with tolerance, physical dependence, paradoxical hyperalgesia, risk of overdose, and misuse. However, for many of these same reasons, COT is also qualitatively more difficult to discontinue than most interventions. This chapter discusses the literature on COT for chronic pain. It recommends a set of parameters clinicians treating chronic SCD pain can use to develop a strategy to manage the risk of COT, while simultaneously assessing success or failure of COT and managing COT failure.