Screening for problematic prescription opioid use

Understanding the causes of problematic pain management in sickle cell disease: evidence that pseudoaddiction plays a more important role than genuine analgesic dependence

Treatment of painful episodes in sickle cell disease (SCD) is sometimes complicated by disputes between patients and staff and patient behaviors that raise concerns about analgesic misuse. Those concern-raising behaviors could indicate either drug seeking caused by analgesic dependence or pseudoaddiction caused by undertreatment of pain. To make a systematic assessment of concern-raising behaviors and examine their associations with other factors, including DSM-IV symptoms of substance dependence, individual, in-depth interviews with SCD patients were conducted to apply pre-established criteria for concern-raising behaviors. These included disputes with staff tampering with analgesic delivery systems, passing prescribed analgesics from one person to another, being suspected or accused of analgesic misuse, self-discharging from hospital, obtaining analgesic prescriptions from multiple sources, using illicit drugs, and injecting analgesics. Assessments were also made of pain-related symptoms of substance dependence (where behaviors resemble substance dependence but reflect attempts to manage pain, increasing the risk of pseudoaddiction), non-pain-related symptoms of substance dependence (where substance dependence reflects analgesic use beyond pain management), and pain coping strategies (using the Pain Coping Strategies Questionnaire). Inter-rater reliability for the assessment of concern-raising behaviors was high, with Kappa coefficients of 0.63 to 1.0. The most frequent concern-raising behaviors were disputes with staff about pain or analgesics. The least frequent were tampering with analgesic delivery systems and passing analgesics between patients in hospital. The odds of concern-raising behaviors in hospital were raised eightfold by less use of ignoring pain as a coping strategy, and more than doubled by each additional pain-related symptom of substance dependence. Non-pain-related symptoms of substance dependence had no independent effect on concern-raising behaviors. Concern-raising behaviors were more closely associated with pain behaviors that make patients vulnerable to misperceptions of substance dependence than they were with genuine substance dependence. The results show how pseudoaddiction can adversely influence hospital pain management, and suggest that more emphasis should be placed on patients' pain and analgesic needs when responding to concern-raising behaviors in hospital.

Responsible prescribing of opioids for the management of chronic pain

The management of patients with chronic pain is a common clinical challenge. Indeed, chronic pain is often inadequately controlled in patients with cancer and in those with non-cancer chronic pain. Because of the complex nature of chronic pain, successful long-term treatment is more difficult than for acute pain. Most often acute pain is nociceptive, whereas chronic pain can be nociceptive (i.e., in response to noxious stimuli), neuropathic (i.e., initiated by a primary lesion or dysfunction in the nervous system) or mixed in origin. Opioids are the current standard of care for the treatment of moderate or severe nociceptive pain. Opioids mediate their actions by binding and activating receptors both in the peripheral nervous system and those that are found in inhibitory pain circuits that descend from the midbrain to the spinal cord dorsal horn. Opioid agonists exert a number of physiological responses including analgesia, which increases with increasing doses. The use of opioids to manage pain in patients with cancer is well accepted. The WHO step-wise algorithm for analgesic therapy based on pain severity reserves the use of opioid therapy for moderate and severe pain. The WHO algorithm has proven to be highly effective for the management of cancer pain. However, the use of opioids to treat patients with chronic non-cancer pain is controversial because of concerns about efficacy and safety, and the possibility of addiction or abuse. The results of clinical surveys and retrospective case series involving patients with non-cancer chronic pain have been inconsistent in regard to resolving these controversial issues. The oral route of drug administration is most appropriate for patients receiving opioids; although rectal, transdermal and parenteral routes of administration are used in specific situations. For continuous chronic pain, opioids should be administered around-the-clock and several long-acting formulations are available that require administration only once or twice daily. Opioid doses should be titrated according to agent-specific schedules to maximise pain relief and maintain tolerability. Adverse effects include constipation, nausea and vomiting, sedation, cognitive impairment and respiratory depression. Tolerance to the analgesic and adverse effects as well as physical dependence, which causes withdrawal symptoms upon discontinuance, may occur with opioid use. Estimates of addiction rates among patients with chronic non-cancer pain range from 3.2 to 18.9%. Successful pain treatment and symptom management is an attainable goal for the majority of patients with chronic pain. Further controlled clinical trials are needed to define the role of opioid therapy in chronic non-cancer pain, and to establish criteria for patient selection and specific treatment algorithms.

Assessment of efficacy of long-term opioid therapy in pain patients with substance abuse potential

Clinical experience supports the notion that opioids can be used successfully to treat many chronic pain conditions. Unfortunately, few controlled trials have assessed which individuals benefit from long-term opioid therapy, and there is concern about the use of long-term opioid therapy in individuals with a substance-abuse history. This article contains three sections relevant to the assessment of individuals with chronic pain and a substance-abuse history who are receiving long-term opioid therapy. The first reviews the literature on opioid therapy, with a critique of biologic and environmental susceptibility factors for addiction. The second briefly reviews uncontrolled and controlled trials of opioid therapy for pain. The third reviews areas critical in assessing treatment efficacy and substance abuse in patients with chronic pain, both in terms of documentation of past behaviors and as a measure of outcome of opioid therapy. Potential guidelines for use of opioids in patients with chronic noncancer pain are outlined. Finally, questions are posed for future investigations of the efficacy of opioid therapy for patients with chronic pain and a substance-abuse history.

A biopsychosocial overview of pretreatment screening of patients with pain

The prevalence and excessive cost of pain, especially when the pain becomes chronic, remains a major health-care problem in the United States. Currently, a biopsychosocial perspective of pain has been found to be the most heuristic approach to understanding and managing it. Using this perspective, an important advance has been made in the possibility of individually tailoring treatment for each patient, with the result being better outcomes. The author reviews the extant literature demonstrating a robust "psychosocial disability factor" among injured workers that is important not only in pain perception, but also in the subsequent development of chronic pain-related disability. Such results emphasize the importance of taking into account how psychosocial and physical factors are intertwined in a complex way in determining pain symptomatology. On the basis of these findings, a number of surgical pre-screening approaches have been developed and found to be effective for maximizing surgical outcomes as described by Carragee, Epker, and Block in other papers in this special topics series. Recently, several organizations in the U.S. have also developed new standards for the evaluation of pain. For example, the Joint Commission on Accreditation of Health Organizations (JCAHO) now requires that physicians consider pain as a "5th vital sign" in evaluating patients. Such initiatives have created a new mandate to regularly assess and manage all types of pain. The use of opioids, as well as implantable pain-management modalities, are among the options. The author notes that the literature on these modalities focuses on interdisciplinary patient-screening approaches prior to their administration as a way of maximizing treatment outcomes. The papers by Praeger, Jacobs, and Robinson et al. in this special topics series describe the approach to pretreatment assessment for these modalities in detail. Finally, the author presents a stepwise, biopsychosocial approach as the basis for assessment before decisions regarding surgery, opioid maintenance therapy, and implantable pain-management modalities. The author suggests that systematic pretreatment interventions will facilitate a more structured standard of care in the evaluation and treatment of patients with pain and ultimately better outcomes.