[27] A 2008 review discovered that of all long-term opioid therapy at that time, more than 90% was being prescribed for chronic non-cancer pain. Between 1997 and 2002, oxycodone prescriptions alone quadrupled[28] and a 2009 study reported that more than 3% of all adults in Selleckchem Erlotinib the US were receiving long-term opioid therapy for chronic non-cancer pain.[29] During the same period, opioid addiction and its consequences, including deaths from unintentional overdose, markedly increased. Between 1985 and 2005, data from the National Vital Statistics

System of the Centers for Disease Control and Prevention show that the death rate from unintentional drug overdose increased by nearly 600%, much of this is due to prescription opioid abuse.[6] During the same roughly 20-year period, trends in treating patients with frequent headaches paralleled the dramatic rise in opioid use for non-malignant pain. Guidelines published by the American Pain Society in 2009 proposed chronic headache disorders as one

of the 4 common chronic pain conditions where chronic opioid therapy might be considered.[30] And APO866 cost a number of regimens for continuous opioid therapy have been devised for patients with refractory CM and other intractable chronic headache disorders (Table 5). However, evidence for the effectiveness of chronic opioid treatment of CM patients is lacking. Saper et al have followed a large cohort of refractory headache patients treated with daily opioid therapy, and while initially promising, results have begun to look bleak.[31, 32] While about one quarter of the 160 enrolled patients seemed to attaining a 50% or better improvement (using an index of severe

headache activity), other measures were much less encouraging, and there was serious question as to the validity of patients’ self-reporting. Disability scores, for example, did not improve even for this group, see more and behaviors such as drug-seeking and dose violation seemed to persist for many. Other reports suggest better results for opioid therapy in headache,[33, 34] but all are fraught with a number of pitfalls. First, when comparing active and placebo responses, maintaining good blinding is probably impossible because of the euphoric and sedating properties of opioids. Related to this is the presumed tendency for patients to exaggerate improvement with opioids do to the anxiolytic and other beneficial effects on mood, not to mention the potential impact of habituation. Adverse effects to opioids may be amplified when use is daily. Significant gastrointestinal dysfunction in particular has been seen in many patients on continuous opioid therapy. The “opioid bowel syndrome” can include intractable severe abdominal pain, which in some cases leads to inappropriate escalation of opioid medication.[35] The most worrisome potential adverse effects from regular opioid use are respiratory depression and sudden cardiac death presumably because of arrhythmia.