Opioid treatment for chronic pain has been popularized over the past few decades, and opioid usage has increased several-fold. Opioid treatment of chronic pain increased for several reasons: a sense that chronic pain had previously been undertreated; strong underwriting of medical education by drug companies anxious to sell new "designer" opioids; lifting of the stigma associated opioids, particularly as pain advocacy reestablished opioids as necessary and appropriate treatment for acute and cancer pain. What has emerged is that there are several limitations to chronic opioid treatment. What has become clear in this unfortunate history is that non-specialists were persuaded to prescribe opioids before they could possibly understand the complexity of the treatment. So great were the pressures to prescribe, from drug companies, advocates, and many well-meaning people who saw opioids as the panacea for suffering, opioids were prescribed indiscriminately. It became almost impossible to deny opioids without seeming inhumane. What we learned though, is that while carefully selected and managed opioid therapy can benefit certain patients, casual use fails in several respects. What is needed then is a vast educational effort to help clinicians understand some of the complexities of opioid therapy, and in particular, how to select patients, and subsequently manage and monitor so as to achieve continued efficacy without losing control of pain and drug use. While no one educational effort can solve the whole problem, this book aims to provide clinicians with expert opinion on how to manage certain common scenarios involving opioid management of chronic pain. It will provide the reader not only with an easy reference to the management of common clinical scenarios where opioids are involved, but also with in depth analysis of the difficult issues surrounding a treatment that is both uniquely effective and potentially harmful.

Dr. John Loeser will be remembered for his founding and sustained leadership in the field of pain medicine. Yet, before the field of pain medicine even existed, he was a highly respected neurosurgeon, co-author of the definitive text on neuroembryology, a decorated Vietnam veteran, husband and a father of three. When he became swept up into the pain world, the idea that pain management should be a medical discipline was new. The founders of the discipline believed that medicine could do a much better job of reducing people’s physical pain (pain felt in the body) using better diagnostics, newer technologies, better knowledge of pain mechanisms and processes, focused pain interventions, and newly developed drugs. There was much excitement in the air because the participants strongly believed that they were on the road to significantly reducing human suffering. But as with many grand initiatives, mistakes were made, some of which caused iatrogenic harm. John Loeser’s great strength was that, despite sharing all initial enthusiasms, he always recognized when assumptions had been wrong, and spoke out early and clearly. Today, four decades after the heady days of the founding of pain medicine, one can ponder what those four decades have achieved. In fact, despite setbacks, what has been achieved is much more than was even hoped for: science has provided important insight into the mysteries of pain. This insight is already helping those who suffer pain through improved channeling of resources, avoidance of iatrogenic harm, and realistic expectations. As the story of John Loeser unfolds in this book, so does the story of pain medicine. That link exists because John’s involvement in pain medicine has spanned its history, and so has become his primary identity. The manuscript is complete.