EditorÐThe use of opioids for non-cancer pain indeed remains a controversial subject. Simpson has given an excellent overview. 1 One particular area of concern is that there are few available data regarding the ef®cacy and safety of high dose opioids given over years rather than months. Whereas it was previously thought that unlimited dose escalation was at least safe, this dogma has recently been questioned. 2 Long-term use of opioids may be associated with the development of abnormal sensitivity to pain, 3 immunosuppression, and hormonal changes. I have found measurement of testosterone levels and replacement therapy to be an important consideration in male patients presenting with loss of libido in such circumstances. Patients with chronic pain may have symptoms that last 24 h a day, but short-acting opioids offer relief for only 3±4 h. For these patients, I generally recommend the use of long-acting opioids. Use of long-acting opioids may result in more predictable serum levels, less abuse, less reinforcement of drug-taking behaviours, and improved sleep, compared with short-acting opioids. The toxicity of acetaminophen is also avoided. 4 5
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