Buprenorphine became available for office-based treatment of opiate dependence in January 2003, at which time the Underwood-Memorial Hospital Family Practice Residency Program began offering buprenorphine treatment at its family practice center. This article describes the patient selection process, outcomes, and obstacles to treatment. Patients who had a pharmaceutical benefit were much more likely to remain in treatment than those who had to pay for the medication. The authors are not aware of other residency programs currently providing buprenorphine training, and postulate reasons why family physicians in the United States have not readily adopted the office-based opiate treatment model.

Physicians have embraced the concept of long-term opioid treatment for chronic noncancer pain (CNCP), as evidenced by increased prescribing. Many patients have benefited from more liberal opioid prescribing, but many have not, and prescription opioid abuse has risen significantly coincident with increased prescribing. Because of the potentially serious adverse effects of opioids, physicians must balance potential benefits against risks, especially in individuals at risk for opioid misuse, abuse, or dependence. This article reviews long-term, continuous opioid treatment of CNCP, current treatment guidelines, addiction risk stratification, opioid-induced hyperalgesia, and endocrine dysfunction.

No abstract

Distinct from Chapter 24, on co-occurring psychiatric disorders, this chapter addresses common physical comorbidities that give rise to chronic pain and are notorious for associated substance use disorders. The concept of “pseudo-addiction” is explored as one of several contributors to common misperceptions of the analgesic needs of such patients. Examples of entities discussed are chronic low back pain, sleep apnea, chronic pancreatitis, cirrhosis, and HIV infection or AIDS-related pain. While not intrinsically painful, sleep apnea merits inclusion as it arises in conjunction with sedative-hypnotic, opioid, or nicotine use. Cirrhosis likewise creates obstacles to successful pain or addiction management resulting from altered metabolism of medications and enhanced susceptibility to potentially lethal syndromes (hepato-renal syndrome, gastric hemorrhage, etc.). The management of neuropathic pain in HIV infection (Chapter 15) is amplified here.