The abuse of opioids falls into two distinct categories of users, those who initiate use solely for recreational purposes and those who become physically dependent as a result of being treated medically with opioids. As discussed in Chapter 26, the primary use of opioids is for the control of moderate to severe pain. However, few patients receiving opioids for pain management become dependent. Furthermore, dependence is less likely if opioids are used judiciously. Acute pain can be controlled with opioids such as hydromorphone or oxy-codone, which have a rapid onset and short duration of action. In contrast, chronic pain is better treated with opioids such as methadone or morphine (e.g., Duramorph, MS Contin), which are less likely to produce euphoria because of their slow onset of action. Dependence in patients is most likely to occur in those with pain of unexplained or poorly defined etiology. Avoiding long-term use of opioids in this population reduces the risk of developing dependence. Development of dependence should not be a consideration in the management of terminal cancer pain.
The primary illicit opioid is heroin (diacetylmor-phine), which was once used almost exclusively by the intravenous route. In recent years, the purity of street heroin has risen to levels that allow it to be smoked or snorted.
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