Identifying Abusers Prior to Initiating Chronic Opioid Therapy
In the 1980’s until the mid-1990s, opioids were accepted as the mainstay of cancer pain treatment.1 Yet, in interdisciplinary programs for patients with chronic pain of nonmalignant origin, the use of opioid analgesics was considered problematic2 and detoxification from opioids was considered a primary goal of treatment.3,4 In 1996, Portenoy5 suggested that there was a subpopulation of patients with chronic pain of benign origin that could benefit from chronic opioid therapy—without intolerable side effects or the development of aberrant drug-related behavior. At that time, the pain management community witnessed a clear swing of the pendulum, resulting in the widespread use of progressively increasing dosages of strong opioid analgesics.
Today there still exists a degree of consensus that such treatment may be beneficial to certain patients suffering from chronic pain of nonmalignant origin. Yet, concerns regarding the potential abuse of prescription opioids are mounting. While initial estimates of potential prescription opioid abuse among chronic pain patients was thought to be quite low—with Portnoy and Foley6 estimating that only 5% of such patients were at risk—some recent estimations range significantly higher.7-14 In 2002, Joranson and colleagues15 determined that the rate of prescription opioid abuse in the United States increased 71% between 1997 and 2002. It has also been reported that while prescription opioids accounted for 5.75% of drug abuse in the United States in 1997, this figure had risen to 9.85% by 2002.16 Finally, Cicero and colleagues17 recently reported (in late 2007) that rates of prescription opioid abuse have increased every quarter over the past 3 ½ years. It is uncertain whether the increase in prescription drug abuse is by pain patients, per se, or diversion by pain patients, manufacturers, pharmacies, or wholesalers. Regardless, all prescribing physicians must attempt to balance abuse, diversion, and therapeutic risk.
While the physician is morally obligated to relieve pain and suffering, he/she must simultaneously attempt—within his or her practice mileu—to identify potential abusers and diverters. Unfortunately, the “science” of risk assessment is still in its infancy, and selection remains an overwhelming challenge. Ideally, physicians prescribing opioids to patients with chronic pain will consult with an appropriately trained and experienced pain psychologist in order to obtain an evaluation that will serve as a guide in the selection process. Tragically, however, access to qualified pain psychologists appears to be becoming progressively more limited, with this scarcity more pronounced in non-urban areas. Schatman18-20 has written extensively about the demise of the multidisciplinary chronic pain management clinic over the past decade. Many of these pain treatment facilities that have closed their doors due to financial factors were housed in teaching hospitals that offered fellowship training programs to psychologists that intended to specialize in pain management. Turk and Burwinkle21 have noted the paucity of training opportunities in interdisciplinary treatment available to psychologists. Within the Veterans Administration, the initial lack of availability of pain psychologists to treat injured veterans of Operations Enduring Freedom and Iraqi Freedom has been noted.22 Additionally, many fellowship-trained pain psychologists have chosen to pursue academic careers as opposed to serving as much-needed clinicians.23 Accordingly, the rest of this article will focus on strategies that physicians can implement in order to increase the likelihood that the patients to whom they are prescribing opioids for chronic pain are at the lowest possible risk for abuse of these potentially beneficial yet dangerous medications.
Behaviors Indicative of Prescription Opioid Abuse
Confusion and disagreement regarding what constitutes prescription opioid abuse has been apparent. Butler et al.24 offered a reasonably comprehensive list of behaviors that are indicative of abuse:
- Selling prescription drugs
- Forging prescriptions
- Stealing drugs
- Injecting oral formulations
- Obtaining prescription drugs from non-medical sources
- Concurrently abusing ETOH or illicit drugs
- Escalating doses on multiple occasions or otherwise failing to comply with the prescribed regimen despite warnings
- “Losing” prescribed medications on multiple occasions
- Repeatedly seeking prescriptions from other physicians or ER’s without informing the original physician
- Deterioration of function relating to drug use.
Risk Factors for Prescription Opioid Abuse
While the body of published research addressing risk factors for opioid abuse in general is substantial, investigations identifying chronic pain patients at risk for prescription opioid abuse are relatively scarce. It is important to recognize that neither the risk factors identified in the general population nor the assessment tools utilized to identify can necessarily be generalized to the chronic pain population, as the circumstances of their distress and predisposing psychological factors of the groups are not identical. Accordingly, the studies cited in this analysis shall be limited to those specific to patients suffering from chronic pain. For this population, predictors of prescription opioid abuse that have been investigated are summarized in Table 1.
Lifetime History of Substance Abuse. One of the strongest predictors of prescription opioid abuse among chronic pain patients is thought to be a lifetime history of substance abuse.6,8,11,12,25-27 Interestingly, while current substance abuse has been found to be predictive of prescription opioid abuse, this risk factor has been examined in only several investigations.8,13,28 Not surprisingly, histories of polysubtance abuse have been found to be more predictive of prescription opioid abuse than have histories of single substance abuse.12,13,29-31 Several studies have identified the risk factor of arrests for DUI’s or drug-related offenses.7,13,32 While a Medline search yields thousands of studies indicating that family histories of substance abuse put relatives at heightened risk of abuse in the general population, only investigations by Michna et al.33 and Akbik et al.34 identify family history as a risk factor for prescription opioid abuse.