Chronic Refractory Angina

Opioids

Opium has been used as an analgesic for many thousands of years. This century a number of strong opioids have entered clinical practice, developed by a burgeoning pharmaceutical industry seeking the `holy grail' of a drug with all the benefits of morphine and none of the drawbacks. The discovery of the endogenous opioids endorphin and enkephalin, together with their receptors, in the 1970's has led to greater understanding of the modes of action of opioid drugs. However, their long-term use in situations other than cancer pain is widely regarded with suspicion within and without the medical profession. Fear of stigmatisation and addiction limit their widespread use in severe chronic non-malignant pain, although there is a growing acceptance of their application in this situation. The development of novel routes of administration and drug formulation has gone a long way towards this.

The World Health Organisation describes an analgesic ladder in the drug treatment of pain, starting with mild analgesics such as aspirin or paracetamol, moving through medium-strength preparations such as codeine or dihydrocodeine, and finally to strong opioid drugs such as morphine if pain control is unsatisfactory.

There is little published work on the treatment of RAP with strong opioids, although there are anecdotal reports of treatment with preparations such as sustained-release morphine or transdermal fentanyl. The introduction of implantable refillable pumps that can deliver opioids intrathecally in tiny volumes (0.1- 2 millilitres of solution per day) may offer an alternative route of administration of these useful drugs that may limit troublesome side-effects and prove more acceptable to patients and their clinicians. See nursing chapters on continuous infusion pump and bolus pumps.

It is clear that much work remains to be done in evaluating the place of strong opioids in the management of chronic refractory angina.

If opioids fail

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