Taking Control: Emerging Issues in Pain ... - Pharmacy Times

The Opioid Pendulum
Opioid Abuse and Addiction
Opiophobia
Balance of Addiction
Medicine and Pain
Management
Principles 1
Opiophillia
• In past, estimated ˂1% of individuals treated for
pain became addicted to opioids
• Now estimated 6%-15% of Americans addicted to
drugs
• 2010: estimated 22.1 million Americans, or 8.7% of
the population of persons ≥ age 12 have substance
dependence and abuse
1 Gourlay, D.L. et al. (2005). Universal precautions in pain medicine: A rational approach to the treatment of
chronic pain. Pain Medicine, 6(2), 107-112.
Marks RM, et al. Ann Intern Med. 1973;78:173-181.
Commonly Used Terms
What are the differences
• Physical dependence: Withdrawal syndrome would occur if
medication discontinued abruptly, dose reduced rapidly, or
antagonist administered 1,2
• Tolerance: Greater amount of medication needed to maintain
therapeutic effect, or loss of effect over time 2
• Pseudoaddiction: Behavior suggestive of addiction caused by
undertreatment of pain 2 ; can be major barrier to appropriate
treatment of patients in pain
• Addiction (psychological dependence): Biopsychosocial
disorder characterized by continued compulsive use of substance
despite harm 2,3
Who is abusing prescription opioids
We don’t know specific subpopulations who are
abusing…do they include
• Persons who abuse or are dependent on only prescription
opioids
• Heroin abusers who use prescription opioids when heroin
unavailable
• Abusers of other drugs who abuse opioids either alone (for
alternative high) or in combination with other drugs (poly-drug
abuse)
• Pain patients who, during course of legitimate treatment,
develop iatrogenic addiction
• Number thought to be low, but definitive studies unavailable
1. APS. Guideline for the Management of Cancer Pain in Adults and Children. Glenview, Ill: American Pain Society; 2005.
2. Savage SR et al. APS Consensus Statement. Glenview, Ill: American Pain Society; 2001. 3. Fishbain DA et al. Clin J Pain. 1992;8:77-85.
Aberrant Drug-Related
Behaviors
Probably more predictive
• Selling prescription drugs
• Prescription forgery
• Stealing or borrowing another patient’s drugs
• Injecting oral formulation
• Obtaining prescription drugs from non-medical sources
• Concurrent abuse of related illicit drugs
• Multiple unsanctioned dose escalations
• Recurrent prescription losses
Aberrant Drug-Related
Behaviors (cont.)
Probably less predictive
• Aggressive complaining about need for higher doses
• Drug hoarding during periods of reduced symptoms
• Requesting specific drugs
• Acquisition of similar drugs from other medical sources
• Unsanctioned dose escalation 1-2 times
• Unapproved use of drug to treat another symptom
• Reporting psychic effects not intended by clinician
Passik and Portenoy, 1998.
Passik and Portenoy, 1998.