Opioids: Balancing Pain Relief With Risks
Highlight from the World Congress of the World Institute of Pain.
As the autopsy report that Prince died of a fentanyl overdose confirms, the incidence of opioid overdose and abuse has increased dramatically in recent years. In the wake of this public health crisis, opioid prescribing practices are being scrutinized by the federal government.
“The whole issue related to addiction has weighted down the scale, to the point that physicians are fearful of using opioids because of all of the bad press,” Jeff Gudin, MD, director of pain and palliative care for Englewood Hospital and Medical Center, in Englewood, NJ, told a group of physicians at the World Congress of the World Institute of Pain in New York City, May 29, 2016.1 His talk, The Interface Between Pain and Addiction, covered just how to walk this tightrope as safely as possible.
Dr. Gudin believes physicians can continue to use opioids as long as they screen patients and monitor them appropriately. The most difficult patients to handle are not the ones with obvious risks—those with a history of addiction, actively abusing drugs, or on methadone maintenance, he explained. Nor are they the “nice little old lady” who doesn’t particularly like the way opioids make her feel, who doesn’t smoke or drink, and who has a good support system at home.
It’s the patient in the middle—and there are many—patients with psychological issues, coping difficulties, and patients who may be using pain medications to help cope with stress, anxiety, insomnia. “We can’t be judgmental towards our patients and call everyone an addict, but we have to understand that this type of patient is associated with chemical coping,” said Dr. Gudin. These patients may not be addicted but there’s a spectrum of patient behaviors that may reflect misusing or abusing opioids, which in and of itself can be harmful, and could also lead to addiction down the road, he noted.
Before prescribing opioids, physicians need to screen patients for risk factors. Some demographic risks include being male, though the numbers of women abusing opioids is on the rise, said Dr. Gudin.
In fact, one factor in the decreasing life expectancy of white women in the US is drug overdose, according to a report by the Centers for Disease Control and Prevention.2 The author of the CDC report told NPR that although many causes of death have declined—including heart disease, cancer, and stroke—those health improvements were offset by the increases in drug overdose, suicide, and chronic liver disease.3 Other demographic risks include living in rural environments and being low income.
Psychological risk factors include a history of substance abuse, which could be alcohol, long-term opioid use, or prescription drug use (ie, doctor shopping, filling out multiple prescriptions). Importantly, mental health disorders such as depression, anxiety, obsessive compulsive disorder (OCD), bipolar disorder, and ADHD correlate strongly with misuse and abuse. Among those with a mental disorder, the lifetime risk of having an addiction is about 29%.4
Almost one quarter of those with anxiety disorders have substance abuse, 60% of those with bipolar have substance abuse,4 33% of those with OCD, and 70% of those with untreated ADHD, according to Dr. Gudin. “I would be very careful treating these patients, making sure to keep those controls around them,” he said.
These controls include educating the patient about appropriate and inappropriate use. Establish functioning and pain relief goals, such as being able to walk the dog, play with the grandchildren, work, etc. About 30% pain relief is considered an appropriate goal. Explain to the patient that complete pain relief is rarely achieved. Use Patient Prescriber Agreements (PPAs)—these are consent forms rather than contracts (ie, risk versus benefits of opioid therapy, what will happen is you misuse opioids, etc.)
It’s also important to monitor the patient for aberrant behavior (misuse or abuse). “The pain patient can get into trouble and we don’t recognize it,” said Dr. Gudin. Physicians should try to get as much information as possible on how the patient is using opioids. He suggests implementing a policy in which the patient brings in a "significant other" or family member about twice a year. A spouse or close family member can bring to light how a patient is really using the medication or any aberrant type behavior, he said.
When seeing the patient, look at quality of life indicators. In a pain patient who is using opioids appropriately, quality of life and functioning should go up. Inappropriate use can lead to quality of life and functioning going down. A regular screening can include questions about functioning at home and work, and interpersonal relationships. Some maladaptive patterns include:
- Poor functioning at work or home life
- Persistent social or interpersonal problems
- Decreased social activities (isolation)
- Using the opioids in higher doses or more frequently than prescribed
- Overusing medications despite efforts to control use
- Craving or strong desire to use opioids.
These behaviors can be mild, such as a patient running out of medicine before the next refill. But they need to be addressed on an individual basis. The question is did the patient run out of medicine at day 27 or after a week? “The patient who runs out after a week has a problem. The one who runs out at 27 days may or may not have a problem,” said Dr. Gudin.
If there are concerns about misuse, physicians may need to taper the patient off opioids, have exit strategies, and structure their therapy differently. Lastly, Dr. Gudin recommends physicians always have resources available for substance abuse treatment facilities to refer patient too.