That was around the time that it had become common practice to prescribe long-acting opioids for patients in the final stages of cancer to relieve the pain of expanding lesions in bone and soft tissue. Because life expectancy was limited, physiologic dependency or addiction was not of concern. A letter in the New England Journal of Medicine in 1980 carried the headline, “Addiction rare in patients treated with narcotics,” and this concept was widely accepted, despite the fact that the assertion was not supported by evidence.1
In 1982, I began the clinical year of my rheumatology fellowship and was shocked to find that our revered senior clinician frequently prescribed propoxyphene napsylate with acetaminophen (Darvocet-N) to severe chronic rheumatoid arthritis (RA) patients.
Propoxyphene is a synthetic compound chemically related to methadone approved by U.S. Food & Drug Administration (FDA) in 1957—five years before evidence of efficacy was required in 1962. Of course, this was pre-methotrexate/pre-early administration of disease-modifying antirheumatic drugs (DMARDs), and these were patients with extensive damage and deformities.
I observed that his patients did not abuse this analgesic and that it did not have the upper gastrointestinal tract toxicity of aspirin. The similar toxicity of non-steroidal anti-inflammatory drugs (NSAIDs) was not recognized for a few more years. So in the early 1980s, I became comfortable regularly prescribing propoxyphene for RA patients with significant chronic pain, which was almost everyone at the time. Questions about its efficacy existed, but I don’t recall problems with tolerance with increasing doses or abuse.
Chronic Non-Malignant Pain
Over time, more attention was given to patients with chronic non-malignant pain. Shortly after I began practice in Wisconsin in 1986, I vividly recall the cover of Newsweek calling attention to this problem: “Why does someone need to be dying to have pain relief? Why are doctors not doing more to relieve severe chronic pain, which is so detrimental to the quality of life of these people?”
A huge leap was taken in believing that the treatment of chronic non-malignant pain would follow the model of treating cancer pain.
The issue of the suffering of those with chronic pain became prominent not only in the lay press, but in the medical literature as well. In 1986, the journal Pain published an article advocating chronic opioid therapy for intractable, non-malignant pain.2 During my 10 years at Marshfield Clinic in Wisconsin, I managed many chronic pain patients with guidance from pain specialists in the anesthesia department.
