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

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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.
Addiction or Chronic Pain Source of Diverting Drugs Addiction • Medication use • Out of control • Impairs quality of life • Continues despite adverse effects • Unaware/in denial of any problems • Doesn’t follow agreement • Doesn’t have leftover med • Loses prescriptions • Always has a story Chronic Pain • Medication use • Not out of control • Improves quality of life • Desire to decrease meds with adverse effects • Concerned about physical problem • Follows agreements • Frequently has leftover meds • Forged and Altered Prescriptions • “Doctor Shoppers” • Prescribers/ Dispensers of Rx Drugs • Theft (Health Facility and Other) • Package Theft/ Diversion (UPS/DHL/FedEx) • Internet • Pharmacy Robbery & Burglary • International Smuggling Fishman S. Responsible Opioid Prescribing. 2nd ed. Washington DC, Waterford Life Science, 2012:30. Top RX Drug Abuse • Hydrocodone (Lortab, Vicodin, Lorcet) $6-$8 • Vicodin: #1 prescribed drug (2006-2010) • Oxycodone (Percocet, Percodan) $6-$8 • Oxycodone IR- $1 mg • Oxymorphone (Opana/Opana ER) $10- $40 • Methylphenidate (Ritalin) $10- $12 • Hydromorphone (Dilaudid) 4 mg - $60 • Alprazolam (Xanax) $3 • Fentanyl (Duragesic/ Actiq) $8- $40 • Methadone ($10- $40 per dose) The Growth of Prescription Monitoring Programs 2003 • 14 states had monitoring programs • 36 states had no prescription monitoring programs Data collected from http://www.pmpalliance.org/content/data 2012 • 41 states had prescription drug monitoring programs • 9 states had no monitoring program Management of Risk: A “Package Deal” Screening for Substance-Abuse Potential • Screening & risk stratification • Compliance monitoring: • Urine screening • Pill/patch counts • Education on drug storage & sharing • Psychotherapy • Highly “structured” approaches • Abuse-deterrent formulations Predictive of Aberrant Behavior Alcohol consumption Drug use Smoking Age Use Caution With: Men who drink >4 alcoholic beverages per day or >16 per week Women who drink >3 alcoholic beverages per day or >12 per week Persons who admit to recreational use of marijuana or hashish in previous year Persons who are
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