Policy issues and imperatives in the use of opioids to treat pain in substance abusers

Chronic Pain Management with Opioids in Patients with Past or Current Substance Abuse Problems

Among patients who present to medical providers with chronic pain complaints, there is an elevated prevalence of illicit substance use and prescription misuse. For those with legitimate pain, this predicament potentiates the risk of being medically underserved or undertreated. Complicating factors include a lack of specificity and sensitivity to the issue of defining substance abuse or misuse in the health care setting. Irrespective of whether patients have histories of addiction, problematic behavior manifests during the course of chronic pain therapy, making a conceptualization of the nature and function of this behavior difficult. The objective of this article is to highlight known confounds in the assessment of “normal” pain-related vs. substance abuse behavior. Our aim is to offer important points to consider, a set of systematic guidelines to follow, and an armamentarium of essential tools to facilitate contingency management planning in the context of treating chronic pain with controlled substances.

Prescription drug use and abuse

When a patient is in physical or emotional pain, prescribing controlled substances often appears to be the simplest and most efficient way to relieve suffering and distress. However, in a minority of cases, this approach leads to prescription drug abuse and patient harm. In this article, the authors review the epidemiologic factors of prescription drug abuse, legal policies designed to safeguard against it, risk factors and red flags, and practical ways to minimize the chances of misuse.

The concept of addiction in law and regulatory policy related to pain management: a critical review

OBJECTIVE

To present a critical appraisal of the present definitions of addiction-related terminology that appear in US laws and regulatory policies that apply to the prescription of controlled substances for pain management.

METHODS

To establish an appropriate context for existing policy definitions, a historical review was conducted of reports from the World Health Organization expert committees on addiction-related concepts, beginning in 1950. In addition, current World Health Organization and American Psychiatric Association diagnostic classification nomenclature were examined. Results from recent criteria-based evaluations of federal and state laws and regulatory policies containing addiction-related terminology also were referenced.

RESULTS

Numerous examples are provided to clarify how inaccurate understandings of the nature of addiction, which can be corroborated by archaic definitions in some states' laws, can impact treatment decisions and patient care. Finally, this article discusses terminological and treatment implications of such concepts as "risk mitigation" and "responsible prescribing", which are goals currently emphasized in the pain management field as principal means to reduce addiction to or abuse of prescription opioid medications.

DISCUSSION

Although notable improvement has been achieved, policy content in some states has not kept pace with advancements in medical and scientific knowledge about the interface between pain management and addictive disease. Effective translation of addiction-related concepts into clinical practice remains an important objective for promoting public health related to treating pain and reducing non-medical use of opioids.

Palliative Care of the Terminally Ill Drug Addict

Palliative care with terminally ill drug addicts is a major challenge for medical professionals to face. With growing problems of prescription drug abuse in this country, the problem is only going to continue to grow and be faced more often. To date, very little has been done focusing on this special population of end-of-life care patients. This review article attempts to explore the terminology and definitions for identifying addiction in the terminally ill as well as exploring management options for healthcare professionals. As with other opioid treated pain patients, relying on terms such as "physiological dependence" and "tolerance" is inappropriate for use in this population, who are likely to have been on opioids for extended periods of time requiring dose escalation for progressive disease. Thus, these terms have little utility for identifying problem patients. Rather, understanding the context of the drug abuse as it reflects on the concepts of use despite harm and the damage inflicted to the physical, psychological, or social make-up of the patient is necessary. Recommendations include careful monitoring and assessment of patients, utilizing multidisciplinary team approaches, encouraging participation in recovery programs, and utilization of pill counts and urine toxicology screenings as necessary. Implications for the field are discussed.

Special issues and concerns in the evaluation of older adults who have pain

Older patients who have pain present unique challenges for clinicians. On the one hand, care must be taken to treat the pain aggressively while avoiding hampering the patient with excessive side effects, such as drowsiness, nausea and vomiting, and constipation. On the other hand, the clinician must be aware of the growing problem of prescription drug abuse and assess whether or not the patient or his or her family is at risk. Indeed, the concern for assessment is not solely centered on the patient but also extends to the family and extended support network, which may or may not have the patient's best interests at heart when it comes to pain medications. Supposing that addiction and abuse are solely the purview of the young is no longer acceptable, and we have the burden of assessing for problematic behavior while also trying to convince some patients that they would benefit from pain medicine.

Urine toxicology screening among chronic pain patients on opioid therapy: frequency and predictability of abnormal findings

OBJECTIVE

To examine the incidence of abnormal urine toxicology screening among chronic pain patients prescribed opioids for their pain and to relate these results to patient descriptors and type, number, and dose of prescribed opioids.

METHODS

A retrospective analysis of data from 470 patients who had urine screening at a pain management program in an urban teaching hospital was performed. Urine samples were analyzed using gas chromatography-mass spectrometry. Patients were categorized as having urine screens that were "normal" (expected findings based on their prescribed drugs) or abnormal. Abnormal findings were those of (1) absence of a prescribed opioid, (2) presence of an additional nonprescribed controlled substance, (3) detection of an illicit substance, and (4) an adulterated urine sample.

RESULTS

Forty-five percent of the patients were found to have abnormal urine screens. Twenty percent were categorized as having an illicit substance in their urine. Illicit substances and additional drugs were found more frequently in younger patients than in older patients (P<0.001). No other variables were found to predict abnormal urine screen results.

DISCUSSION

These results confirm past findings that random urine toxicology screens among patients prescribed opioids for pain reveal a high incidence of abnormal findings. Common patient descriptors, and number, type, and dose of prescribed opioids were found to be poor predictors of abnormal results.

Definitions related to the medical use of opioids: evolution towards universal agreement

Misunderstandings regarding the nature and occurrence of addiction have historically been barriers to the appropriate treatment of pain and have stigmatized the medical use of opioids. This article reviews the evolution of nomenclature related to addiction, presents current scientific understanding of addiction that may help shape universally acceptable terminology, and discusses an integrated effort of pain and addiction professionals to reach consensus on addiction-related terms. The article suggests key principles that may clarify terminology including: clear differentiation of the concepts of addiction and physical dependence, conceptualization of addiction as a multidimensional disease, and use of a label for the phenomenon of addiction that does not include the ambiguous term "dependence." More universal agreement on terminology related to addiction is expected to improve the treatment of both pain and addictive disorders; improve communication between health care providers, regulators, and enforcement agencies; and reduce health care and other societal costs.

Challenges in the federal regulation of pain management technologies

Those who write about pain management have focused almost entirely on delivery issues, paying essentially no attention to the federal regulatory challenges that affect the development of pain relief technologies — namely, pharmaceuticals and medical devices indicated for analgesic uses. The academic literature is strangely devoid of any sophisticated discussion of the difficulties that attend, first, the product approval decisions of the Food and Drug Administration (FDA) and, second, the scheduling decisions made by the Drug Enforcement Administration (DEA). If a “bottleneck” develops upstream, it could have serious repercussions downstream — without pain relief technologies, the issues of access that have preoccupied previous commentators would have little practical consequence.

The modern pharmaceutical industry traces its origins back more than a century, around the time that the German company Bayer first synthesized aspirin (acetylsalicylic acid) and began marketing it as an analgesic.

Abuse and addiction issues in medically ill patients with pain: attempts at clarification of terms and empirical study

The assessment of addiction-related outcomes is crucial to the management of chronic pain with opioid drugs in all patients. Pain management for patients who have concomitant drug abuse or addiction issues is a particularly complex task involving a need for a common nomenclature as well as empirically derived data to support management strategies during treatment regimens. Complicating the issue is the notion of pseudoaddiction, which is an abuse of medications driven by unrelieved pain that appears on the surface to be very similar to the behavior patterns of addicts. For proper adherence to medical therapy and safety during treatment, it is necessary to address and manage substance abuse-related behaviors. Aberrant drug-taking behavior presents many threats to the integrity of pain treatment. Unfortunately, the current state of the art still has a long way to go before clear guidelines for treatment and management can emerge. What is ultimately needed is a broad-based spectrum of research that highlights the epidemiology of drug-taking behaviors for different medical illnesses ranging from cancer to back pain. This article focuses on some of these issues as well as recounting attempts by our research group to address these issues systematically in hopes of shedding light on the nature of abuse issues in the medically ill. Although advances have been made, there is a definite need for large-scale studies that address the issues of identification and treatment of aberrant behavior in medically ill patients in the effort to provide the best possible outcomes for patients with chronic pain.

U.S. policies relevant to the prescribing of opioid analgesics for the treatment of pain in patients with addictive disease

Undertreatment of pain is likely to occur among patients with active addiction or those who have a history of addiction. One of the factors that can contribute to the inadequate treatment of pain in this patient population is the presence of laws and regulations that, when implemented, could impede effective pain management. This article describes the current status of federal and state policy governing the medical use of opioid analgesics for pain management with patients who have an addictive disease in the U.S. Three types of policy barriers are discussed: (1) those that can affect pain management in any patient, (2) those that can lead to patients in pain being classified as "addicts," and (3) those that relate specifically to patients with a high risk of addiction. Also presented are recent policy initiatives that can improve the use of controlled substances to treat pain and, thus, ultimately enhance pain relief for patients with an addictive disease.

Substance abuse issues in cancer pain

It is estimated that 40% to 50% of patients with metastatic disease and 90% of patients with terminal cancer experience unrelieved pain. Furthermore, inadequate treatment of cancer pain is a greater possibility if the patient is a substance abuser. In this paper, we will explore pertinent conceptual and clinical aspects of addiction that can assist in improving the identification and treatment of patients with substance use disorders.

Opioids and the treatment of chronic pain in a primary care sample

Chronic pain is a widespread, difficult problem facing clinicians. This study assessed the current medical management of a general population of patients with chronic pain in 12 family medicine practices located throughout the state of Wisconsin. Medical record audits were conducted on a sample of 209 adults. Sixty-seven percent were female with an average age of 53 years. The most common pain diagnoses included lumbar/low back (44%), joint disease/arthritis (33%), and headache/migraine (28%) pain. The most frequently prescribed opioids were oxycodone/acetaminophen (31%), morphine ERT (19%), Tylenol #3 (15%), and hydrocodone/acetaminophen (14%). Depression/affective disorders were reported in 36% of the patient charts, anxiety/panic disorders (15%), drug abuse (6%), and alcohol abuse (3%). Written drug contracts were utilized by 42% (n = 31) of the practitioners, pain scales 25% (n = 29), and urine toxicology screens 8% (n = 6). This study suggests that primary care practitioners have unique opportunities to identify and successfully treat patients with chronic pain.

Pharmacists' knowledge of and attitudes toward opioid pain medications in relation to federal and state policies

OBJECTIVE

To assess Wisconsin pharmacists' knowledge of and attitudes toward the use of opioid analgesics in the management of chronic cancer and noncancer pain, and to explore the potential for these beliefs to interfere with pharmacist dispensing, the last link of the distribution chain of controlled substances to patients.

DESIGN

Mail survey.

SETTING

Urban and rural pharmacies, long-term care facilities, hospitals, and outpatient clinics in Wisconsin in 1998.

PATIENTS OR OTHER PARTICIPANTS

Representative sample of Wisconsin pharmacists.

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Responses to self-administered questionnaires.

RESULTS

Although most respondents were knowledgeable about the issues addressed in this study, there were important exceptions. Not all pharmacists knew what constitutes legitimate dispensing practices for controlled substances under federal or state policy in emergencies or for patients with terminal illnesses, and many were unaware of the important distinctions among addiction, physical dependence, and tolerance. Many respondents did not view the chronic prescribing/dispensing of opioids for more than several months to patients with chronic pain of malignant or nonmalignant origin as a lawful and acceptable medical practice; this was especially true when the patient had a history of opioid abuse.

CONCLUSION

Pharmacists play a pivotal role in ensuring patient access to medications. Viewed in the context of federal and state controlled substances policies, our findings suggest that the incorrect knowledge and inappropriate attitudes of some pharmacists could contribute to a failure to dispense valid prescriptions for opioid analgesics to patients in pain.

Hyperalgesic responses in methadone maintenance patients

Opioid substitution treatment for dependence may alter sensitivity to pain. Previous studies on pain sensitivity in methadone maintenance patients have yielded contradictory results. This study compared nociceptive responses between 16 patients on stable, once daily, doses of methadone and 16 matched control subjects. Two types of nociceptive stimuli were used: (1) electrical stimulation; and (2) a cold pressor test. Two parameters were measured: detection for onset of pain, and pain tolerance. Methadone patients were tested over an inter-dosing period: at the time of trough plasma methadone concentration (0 h), and 3 h after their daily dose. Control subjects were tested twice 3 h apart. Blood samples were collected to determine plasma methadone concentration. In methadone patients, trough to peak increases in mean R-(-)- and S-(+)-methadone concentrations (118 and 138 ng/ml to 185 and 259 ng/ml, respectively) resulted in significant increases in pain detection and tolerance values for both nociceptive stimuli. Using electrical stimulation, methadone patients' pain tolerance values were lower than controls at 0 h, but higher than controls at 3 h; no significant differences in pain detection values were found. For the cold pressor test, methadone patients detected pain significantly earlier than controls at 0 h, and were also substantially less pain tolerant than controls at both 0 and 3 h. There were no significant differences in pain detection values between the two groups at 3 h. Pain tolerance to pain detection ratios for methadone patients were significantly lower than controls for the cold pressor test at 0 and 3 h, and for electrical stimulation at 0 h only. In summary, the relative pain sensitivity of methadone maintenance patients is determined by the nature of the nociceptive stimulus (e.g. cold pressor test versus electrical stimulation), the plasma methadone concentration (trough versus peak plasma concentration), and whether thresholds are determined for detection of pain or pain tolerance. Although responding to changes in plasma methadone concentration, maintenance patients are markedly hyperalgesic to pain induced by the cold pressor test.

Pain responses in methadone-maintained opioid abusers

Providing pain management for known opioid abusers is a challenging clinical task, in part because little is known about their pain experience and analgesic requirements. This study was designed to describe pain tolerance and analgesic response in a sample of opioid addicts stabilized in methadone-maintenance (MM) treatment (n = 60) in comparison to matched nondependent control subjects (n = 60). By using a placebo-controlled, two-way factorial design, tolerance to cold-pressor (CP) pain was examined, both before and after oral administration of therapeutic doses of common opioid (hydromorphone 2 mg) and nonsteroidal anti-inflammatory (ketorolac 10 mg) analgesic agents. Results showed that MM individuals were significantly less tolerant of CP pain than control subjects, replicating previous work. Analgesic effects were significant neither for medication nor group. These data indicate that MM opioid abusers represent a pain-intolerant subset of clinical patients. Their complaints of pain should be evaluated seriously and managed aggressively.

A titrated morphine analgesic regimen comparing substance users and non-users with AIDS-related pain

To compare morphine dosage and effectiveness in AIDS patients with/without prior substance use and pain, a prospective, open-label case series lasting 3-18 days was conducted in both outpatients and inpatients at major pain service teaching programs. Forty-four patients, 13 with prior drug use history, who had pain associated with HIV infection or its treatment were administered sustained-release morphine (SRM) every 12 hours. The dose was titrated to pain relief for a period of > or =3 consecutive days (associated with < or =2 immediate-release morphine tablets per 24 hours), or until the patient discontinued from the study or completed 18 study days. Forty-four patients were enrolled (13 with a prior drug use history). Forty were evaluable for an intent-to-treat analgesia, including 11 with a drug use history. Twenty-four (6 users) completed this study. Former users and non-users were similar in demographics, baseline pain intensities, causes of pain, discontinuation, quality of life, and acceptability of therapy. Pain intensity decreased by > or =50% in both groups (P < or = 0.0001). To identify a stable dose, the dose of SRM more than doubled in former users and rose by 31% in non-users (mean final dose 177.4 mg and 84.9 mg, respectively) (P = 0.0018). Immediate-release morphine decreased in both; former users required more (P = 0.0006). These data suggest the utility of morphine for AIDS-related pain. Patients with a prior drug use history benefited but required substantially more morphine.