-Pain patients very rarely become addicted.

-Distinguishing between "addiction" and "tolerance."

-There is no such thing as "too much" pain medication for a patient in pain.

-Careful pain management does not kill.

-Prescribing pain medication properly is not illegal.

Most people facing a very serious illness fear dying in pain as much as they fear death itself. But 95 percent of pain, including the worst cancer pain, can be controlled. When lesser painkillers fail, morphine and its synthetic cousins (opioids) should be considered.

Patients and American doctors (who should know better) are unreasonably afraid of opioids. This "opiophobia" is not based on fact, but is a product of outmoded knowledge and the War on Drugs. Medical research demonstrates the utility and safety of opioid use for otherwise untreatable pain. Major medical organizations have created policies and standards to advise doctors on the findings and resultant practice guidelines. A recent joint statement by the American Pain Society and the American Academy of Pain Medicine outlines current goals and standards for the use of opioids in pain management.

Despite this activity at the top of the profession, pain management in hospitals, nursing homes and doctors' offices in the United States falls far short of the standard for medical care. Doctors only recently had good pain management training available to them. They are often very reluctant to use opioids effectively, even when a patient is dying. Many never even consider opioids for long-term therapy for non-cancer pain.

Very sick patients are entitled to the best modes of pain control. They, not their doctors, are the best judges of how much pain they feel and whether a particular mode of pain management is working. For chronic pain patients the key is whether the medications make them better able to function in their daily lives than do more frequently dispensed pain medications.

Opioids are not the answer to every pain problem or even every severe pain problem.  However, every patient should receive consideration of pain that is not clouded by ignorance or unreasonable fear of particular medications.

Pain patients very rarely become addicted.

An addict is a person who compulsively takes drugs for nonmedicinal purposes. Addicts will continue to seek out the drugs despite bad effects on their ability to function in the community, to hold a job, to care for their families and to maintain social relationships. In contrast, pain patients often take very large amounts of opioids and other medications to improve their function, but do not seek out the drug for its own sake or "crave" the medication. Their ability to work, care for families and live productive lives is improved by their medications.

A recent study demonstrates that fewer than one percent of pain patients receiving opioids become narcotics abusers. No patient in pain should hear that relief is barred because "you will become an addict." No patient in pain should reject opioids out of fear of becoming addicted. Even former and current substance abusers can be treated for severe pain by doctors with experience in the field.

"Tolerance" is a physical event that will always happen when a patient takes opioids. Tolerance begins with even one dose. This physical fact is not linked to harmful effects. It means only that, over time, pain patients can be expected to need higher doses of the medication to obtain the same relief.

A patient who has been receiving opioids for pain over time can tolerate levels that would kill a person who is "opioid naive" (someone who has not built up any tolerance). For this reason it is often said that there is no theoretical upper limit to the amount of opioids than can appropriately be prescribed to control pain. Careful physicians will monitor dosage closely and increase it when necessary as tolerance builds to maintain a good effect on pain control. Moreover, some medications mix opioids and other pain relievers such as aspirin, acetaminophen and other non- steroidal compounds. A patient taking these medications will reach a ceiling dose at some point because the other drugs in the compound are toxic. Some pain relievers, such as Demerol, should not be used for any extended period because of toxicity.

Confusion between "addiction" and "tolerance" is common even among physicians.

Identification of patients with substance abuse problems is even more difficult. The best distinction between the two is the patient's ability to function. Pain patients can expect to improve function with optimal dosages of opioids.

"Dependence" is another physical fact. It refers usually to the need to maintain opioid levels in a tolerant individual or experience withdrawal. Both addicts and legitimate pain patients will experience withdrawal if the drug is withdrawn abruptly.

Pain experts agree that there is no "theoretical upper limit" for opioid dosages for pain relief. The upper limit is "what works." It is important not to assume that high dosages or a large number of prescribed pills means that the patient is "an addict." Of course, the doctor must monitor to make sure that the dose is appropriate for that patient.

Morphine and its derivatives do have side effects. The most frequent is constipation. Most side effects can be managed. A doctor may have to try a number of pain medications or combinations of medications to reach the maximum relief with minimum side effects. Patient and doctor need to work together to reach an appropriate dose for the patient.