Introduction

Chronic pain has always been and will remain difficult to manage. There have been important developments in our understanding of the neurobiology of pain, but perhaps the greatest advance is our ability to analyse trial data more critically and to realise that we may have been wrongly optimistic about the use of some therapies. Although the publication of high-quality literature reviews may have reduced our therapeutic options, it also provides an opportunity to improve patient care by ensuring that we are not exposing patients with pain, whose lives are difficult enough as it is, to the harms of medicines that do not help them.

In particular, there is a need to reconsider the place of opioids in the management of chronic pain. This includes the so-called weak opioids (eg, codeine and dihydrocodeine), and strong opioids (eg, morphine, oxycodone, fentanyl and buprenorphine), as well as tramadol (a non-selective agonist at mu, delta and kappa opioid receptors with monoaminergic properties), which should be considered alongside the strong opioids.

Opioids emerged into the chronic pain management scene in the 1990s. The recognition of their potent role in the management of acute and end-of-life pain, the inappropriate adoption of WHO analgesic ladder designed for …