Abuse & Misuse of Opiod Analgesics
Chronic pain is a consequential problem that influences every aspect of an individual’s life, including sleep, employment, social functioning, and activities of daily living. Oftentimes, family roles are altered, due to chronic pain, and the consequences of a limited lifestyle takes its toll on all. Symptoms of chronic pain affect more than 90 million Americans, accounting for 21 percent of all emergency room visits and 25 percent of all missed workdays.1 Patients with chronic pain often experience depression, anxiety, irritability, sexual dysfunction, and decreased energy.1 According to Medical Director at the Pain Management Center at Brigham & Women’s Hospital in Boston, Edgar L. Ross, M.D. and colleagues, opioid analgesics have been found to be useful for managing both cancer-related and non-cancer-related pain.1 Many physicians remain reluctant to support the use of opioids, however, as they are associated with adverse effects, tolerance, and addiction.1 In their article, “Addressing Abuse and Misuse of Opioid Analgesics,” Ross and colleagues discuss issues that are associated with opioid misuse, as well as assessment and treatment strategies.1
Misuse of opioid analgesics is frequent in the U.S., as between 15 and 23 percent of patients meet the criteria for a substance use disorder. Patients at a lower risk of abuse include those who are older, adherent to their medication regiment, functional, have a stable mood, are responsible and considerate, and rarely overuse any medicine.1
According to Ross and colleagues, persons with chronic pain often have significant medical comorbidities that may affect their treatment.1 For example, many patients with chronic pain report having asthma; chronic obstructive pulmonary disease; diabetes mellitus; coronary artery disease; hypertension; ulcers; kidney, bladder, or liver problems; or a history of cancer.1 Sometimes, the medical comorbidities add to the chronic pain. Usually, persons with chronic pain smoke cigarettes, are overweight, have low bone density, and use multiple medications prescribed by multiple providers.1 Ross and colleagues state that assessing and identifying comorbid medical problems will help the clinician treat all of the patient’s disorders, using the best treatment approach for the specific patient.1
It is imperative that all patients undergo an initial comprehensive evaluation before being treated by any clinician.1 This includes taking a thorough medical history, a urine toxicology screen, and a physical examination.1 Communication with the patient’s other medical providers should also be established, and the patient should be informed that rarely are prescription opioids prescribed on the first visit.1
As it is not unusual for patients with chronic pain to have comorbid psychiatric disorders, usually up to 50 percent of the time, a psychiatric examination should also be taken.1 Patients often report feeling depressed, anxious, and irritable, and many have a history of physical or sexual abuse or a mood disorder. In fact, patients with comorbid chronic pain and mood disorder are more likely to be prescribed prescription opioid analgesics, as they state that their distress and pain are more severe than psychical pathology will show. Psychopathology also has a heavy influence on pain and disability outcome for patients with chronic pain. For example, patients with chronic pain and comorbid anxiety and depression had a 62 percent worse return-to-work rate than those without psychopathology.
The United States Department of Justice recommends that physicians increase efforts to identify abuse of controlled substances in their patients, as there is a growing support for the use of opioid analgesics to manage chronic pain. Inappropriate use of opioid analgesics include selling and diverting prescription drugs, seeking prescriptions from multiple providers, using illicit drugs, snorting or injecting the medicine, and using the medicine in a manner not intended.1 Unfortunately, this puts physicians in a difficult positions, as there is not standard for assessing the risk of misuse or abuse of opioid analgesics in patients with chronic pain.1 There are a variety of assessment measures that are available, however. While many have not been formed specifically for the assessment of prescription opioid use, there have been a couple that have recently been developed for such.1 For example, there is the 5-Item Opioid Risk Tool which is a checklist completed by clinicians that predicts whether patients will display drug-related behaviors, for use before prescribing prescription opioids. Another assessment is the Screener and Opioid Assessment for Patients in Pain (SOAPP), which is a 14-item self-administered tool that predicts medication-related behaviors in patients considered for long-term opioid therapy.
Ross and colleagues recommends using a controlled substance agreement to help improve patient adherence through education and mutual consent.1 The agreement informs the patient of their responsibilities when using controlled substances, and should include the following: responsibilities for self-administration of medications, medication refill intervals, pharmacy use, limiting or excluding other physicians from whom prescriptions are obtained, agreement not to use recreational drugs or prescription medications received from other persons, and consent for random drug testing.1 Although the agreement is not a legal document, failure to adhere to any condition can result in a patient’s discontinuation of prescription opioid treatment.1
According to Ross and colleagues, careful monitoring is especially important for persons who are prescribed opioid analgesics for chronic pain.1 Those who are found to be of high risk for misuse should be encouraged to follow an opioid agreement, have regular urine toxicology screens, pill counts, and motivational counseling.1
 Ross, E.L.; Holcomb, C.; and Jamison, R.N. (2009, Feb. 6). Addressing Abuse and Misuse of Opioid Analgesics. Psychiatric Times. Retrieved from http://www.psychiatrictimes.com/display/article/1145628/1469892.
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