Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors

Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history

Physicians can encounter problems in prescribing opioids for some patients with chronic pain such as multiple unsanctioned dose escalations, episodes of lost or stolen prescriptions, and positive urine drug screenings for illicit substances. This study explored the usefulness of questions on abuse history in predicting problems with prescribing opioids for patients at a hospital-based pain management program. One hundred forty-five (145) patients who were taking long- and short-acting opioids for their pain were classified as high or low risk on the basis of their responses to interview questions about 1) substance abuse history in their family, 2) past problems with drug or alcohol abuse, and 3) history of legal problems. The treating physicians completed a questionnaire about problems that they had encountered with their patients. Problem behaviors were verified through chart review. No differences in demographic characteristics were found between those classified as high and low risk. Patients who admitted to a family history of substance abuse, a history of legal problems, and drug or alcohol abuse were prone to more aberrant drug-related behaviors, including a higher incidence of lost or stolen prescriptions and the presence of illicit substances in their urine (P < 0.05). Patients classified as high risk also had a significantly higher frequency of reported mental health problems and motor vehicle accidents. More of these patients smoked cigarettes, tended to need a cigarette within the first hour of the day, took higher doses of opioids, and reported fewer adverse effects from the medications than did those without such a history (P < 0.05). This study demonstrates that questions about abuse history and legal problems can be useful in predicting aberrant drug-related behavior with opioid use in persons with chronic noncancer pain.

Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients

This study constituted the first step in the psychometric development of a self-report screening instrument for risk of opioid medication misuse among chronic pain patients. A 26-item instrument, the Pain Medication Questionnaire (PMQ), was constructed based on suspected behavioral correlates of opioid medication misuse, which heretofore have received limited empirical investigation. The PMQ was administered to 184 patients at an interdisciplinary pain treatment center. Reliability coefficients for the PMQ were found to be of moderate but acceptable strength. Construct and concurrent validity were examined through correlation of PMQ scores to measures of substance abuse, physical and psychological functioning, and physicians' risk assessments. To explore high and low cutoff points for misuse risk, subgroups were formed according to the upper and lower thirds of PMQ scores and compared on validity measures. Higher PMQ scores were associated with history of substance abuse, higher levels of psychosocial distress, and poorer functioning. Future psychometric analyses will consider predictive validity and examine shortened versions of the instrument.

Patient Characteristics and Risks Factors for Development of Dependence on Hydrocodone and Oxycodone

The purpose of the study was to document the substantial increase in problematic use of hydrocodone and oxycodone in an addiction treatment population. Our study consisted of a retrospective review of medical records from all patients admitted and discharged in 2000 from Sparrow/St. Lawrence Addiction Detoxification Unit (N = 534). A literature review was conducted in medical journals, governmental groups, and reports including Drug Abuse Warning Network, Pharmacy Times, and National Household Survey on Drug Abuse. More than 144 patients (27%) were dependent on prescription opiate medications. The most frequently mentioned medication was Vicodin (hydrocodone) (53% of the users) followed by OxyContin (oxycodone) (19%). Physicians commonly prescribed these medications (75% of the cases). Predictors of dependence on opiate medications included substance-related diagnoses, positive toxicology for opiates, and other medical diagnoses. Patients under the care of physicians who have other drug dependence diagnoses and medical complaints appear at risk of developing dependence on prescription opiate medications. Proper evaluation and intervention can limit adverse consequences of prescription opiate medications.

A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies

Although interdisciplinary pain management programs are both therapeutically effective as well as cost-effective, they are currently being underutilized because of managed care policies. We used this prospective comparison trial, with 1-yr follow-up of chronic pain patients, to demonstrate the short- and long-term efficacy of an interdisciplinary pain management program, and evaluate the impact of managed care's physical therapy "carve out" practices on these treatment outcomes. Consecutive chronic pain patients (n = 201) were evaluated, some of whom had their physical therapy "carved out" from this integrated program. Results revealed that successful completion of interdisciplinary pain management was therapeutically effective. Most importantly, physical therapy "carved out" practices had a negative impact on both the short-term and 1-yr follow-up outcome measures. Thus, interdisciplinary pain management is effective in treating the major health problem of chronic pain. However, insurance carrier policies of contracting treatment "carve outs" significantly compromise the efficacy of this evidence-based, best standard of medical care treatment. This raises important medico-legal and ethical issues.

IMPLICATIONS

Interdisciplinary pain management is effective and cost-effective in treating the major health problem of chronic pain. The present study demonstrated its efficacy using a prospective, 1-yr posttreatment evaluation methodology. Moreover, physical therapy "carve out" practices by insurance carriers had a negative impact on the outcomes, raising important medico-legal and ethical issues.

Treating pain patients at risk: evaluation of a screening tool in opioid-treated pain patients with and without addiction

Patients receiving opioid treatment for chronic pain, many of whom were hospitalized with medical complications of substance abuse, were asked to complete a screening questionnaire to help validate a simple self-administered survey. Questions relating to tobacco abuse and prior treatment for drug and alcohol abuse distinguished patients with addiction and pain from opioid-treated chronic pain patients.

The trilateral opioid contract. Bridging the pain clinic and the primary care physician through the opioid contract

We have extended the traditional use of opioid contracts to involve the primary care physician (PCP). The PCP was asked to collaborate with the pain specialist's decision to use opioids by cosigning an opioid contract. Explicit in the agreement was the understanding that the primary care physician would assume prescribing the refills for these medications once the opioid regimen had become stabilized. The present study was a retrospective chart review of the first 81 patients with non-malignant chronic pain who received an opioid agreement requiring the participation of the primary care physician. Sixty-nine of the 81 patients (85%) agreed to the terms of the contract initially, but only 50 of these 69 individuals (72%) successfully obtained their PCP's written agreement for the prescribing of opioids for chronic pain management. Despite expecting reluctance on the part of the PCP to enter into this agreement, the low compliance rate was due to lack of commitment on the part of the patient, who either refused to sign the contract outright or, after initially agreeing to sign the contract, did not have it signed by the PCP. If the PCP did not agree to sign the opioid contract, the patient was tapered off the medication. If the contract was approved and signed by the PCP, there were no subsequent reversals by this physician in terms of agreeing to continue to prescribe opioids. In all cases in which a contract was completed, the patient was successfully stabilized on an appropriate opioid regimen and then discharged back to the care of the PCP for long-term opioid treatment. The opioid contract may be an effective tool for networking specialty and primary care services in the delivery of chronic opioid therapy.

Role of urine toxicology testing in the management of chronic opioid therapy

Recognition is growing that self-report of drug use, prescribed or otherwise, among patients with chronic pain treated with opioids is often unreliable. This fact is well known to the addiction management community. Patients may inaccurately report use of prescribed medications, fail to report use of nonprescribed medications or medications prescribed by other physicians, or fail to report use of illicit drugs. Although there are yet no accepted diagnostic criteria for addiction or other forms of medication misuse in the patient with chronic pain, most clinicians would agree that awareness of a patient's inappropriate use of nonprescribed medications or illicit drugs is relevant to proper patient management. The use of external sources of information, therefore, such as testing of biologic material (e.g., urine), interviews with spouses, review of medical records, or input from prescription monitoring programs, may improve patient management. Of these methods, urine toxicology testing has by far the largest experience. Urine toxicology testing may reveal the presence of illicit drugs, such as heroin or cocaine, or controlled substances not prescribed by the physician ordering the test (e.g., hydromorphone in a patient prescribed oxycodone). The authors review the use of urine toxicology testing in monitoring patients with chronic pain, including laboratory aspects. They also present evidence from recent studies that suggests that monitoring the behavior alone of patients on chronic opioid treatment will fail to detect potential problems revealed by urine toxicology testing. The authors conclude that, although further research is urgently needed, at this time it is appropriate to conduct routine urine toxicology testing in patients with chronic pain treated with opioids.

Assessment and treatment of comorbid psychiatric disorders in opioid-dependent patients

The purpose of this article is to provide a review of the prevalence, assessment, and treatment of common psychiatric disorders found among patients with opioid dependence. Dependence on opioids can include both persons who are physically dependent on opioids and persons who fulfill the criteria for a syndrome of opioid dependence, such as that found in the Diagnostic and Statistical Manual, fourth edition (DSM-IV). The latter grouping of persons typically abuse illicit opioids, and prevalence of comorbid conditions and approaches in diagnosis and treatment have been studied in these patients. High rates of other psychiatric disorders--both other substance-use disorders as well as non-substance-use psychiatric disorders--have been reported. The most common non-substance-use psychiatric disorders are depressive, anxiety, and personality disorders. When evaluating and planning treatment of opioid-dependent patients with concurrent psychiatric symptoms, it is important to determine if such symptoms are independent of the substance use or substance induced. In the former case, treatment should follow routine clinical practice, whereas in the latter case, treatment stability in substance use should be the first therapeutic step. The presence of a pain condition can further complicate assessment and treatment, as either pain itself or treatments used for pain may produce symptoms that overlap with psychiatric disorders.

Ethical perspectives: opioid treatment of chronic pain in the context of addiction

The authors apply eight ethical domains of analysis to the question of treatment of chronic pain with opioids in patients with histories of substance use disorders: autonomy, nonmaleficence, beneficence, justice, medical condition, patient preference, quality of life, and consideration of specific individual or sociocultural issues. These eight domains are drawn from principle-based and case-based ethical perspectives. The domains are developed by review of available literature and through application to a specific presented case. Factors that interfere with rational, ethical decision-making regarding opioid pain management are identified. Chronic pain and substance use disorders share a history of stigmatization, underdiagnosis, and undertreatment. Using the presented case as a point of departure, the authors discuss principles for prescription of opioids for treatment of chronic noncancer pain in the setting of history of substance use disorders.

A new role for opioids in the treatment of arthritis

Arthritis, rheumatic diseases, spinal and peripheral joint disorders share in common a legacy of chronic pain. At the turn of the millennium, nonsteroidal anti-inflammatories (NSAIDs) had replaced aspirin as the agents most commonly used to deal with rheumatic symptoms, including pain. Paracetamol (acetaminophen) was the most common alternative analgesic for minor pain. Opioids were most commonly used on an ad-lib basis, usually for 'breakthrough' pain. However, neurobiological research has confirmed the basis for 24-hour around-the-clock complete suppression of chronic nonmalignant pain. This avoids the 'wind up' that leads to intractable pain progression. Proper monitoring, in the absence of the end organ toxicity seen with NSAIDs, allows a change in direction to opioids for arthritis for more severe pain. This requires understanding the responsibilities of maintaining opioids, in properly selected patients, based upon host response and informed consent. Under such circumstances, evidence-based trials support the use of stronger opioids in recalcitrant chronic pain of arthritis. Thus, we endeavour to better fulfill our Oath of Hippocrates: 'to relieve pain and suffering'.

Pharmacoeconomics of opioid therapy for chronic non-malignant pain

Chronic non-malignant pain (CNMP) is widely prevalent and associated with significant costs. Costs related to chronic pain include medical services and medications, treatment of medication-related toxicity and work absenteeism. The use of non-narcotic analgesics is associated with inadequate pain-relief for many patients, as well as significant and costly organ toxicity. When used appropriately and judiciously, opioid medications can be a useful addition to the treatment plan for patients with CNMP. Opioids can provide long-term, safe and cost-effective pain relief.

Use of opioid medications for chronic noncancer pain syndromes in primary care

OBJECTIVES

To define the spectrum of chronic noncancer pain treated with opioid medications in 2 primary care settings, and the prevalence of psychiatric comorbidity in this patient population. We also sought to determine the proportion of patients who manifested prescription opioid abuse behaviors and the factors associated with these behaviors.

DESIGN

A retrospective cohort study.

SETTING

A VA primary care clinic and an urban hospital-based primary care center (PCC) located in the northeastern United States.

PATIENTS

A random sample of VA patients ( n=50) and all PCC patients ( n=48) with chronic noncancer pain who received 6 or more months of opioid prescriptions during a 1-year period (April 1, 1997 through March 31, 1998) and were not on methadone maintenance.

MEASUREMENTS

Information regarding patients' type of chronic pain disorder, demographic, medical, and psychiatric status, and the presence of prescription opioid abuse behaviors was obtained by medical record review.

MAIN RESULTS

Low back pain was the most common disorder accounting for 44% and 25% of all chronic pain diagnoses in the VA and PCC samples, respectively, followed by injury-related (10% and 13%), diabetic neuropathy (8% and 10%), degenerative joint disease (16% and 13%), spinal stenosis (10% and 4%), headache (4% and 13%) and other chronic pain disorders (8% and 22%). The median duration of pain was 10 years (range 3 to 50 years) in the VA and 13 years in the PCC sample (range 1 to 49 years). Among VA and PCC patients, the lifetime prevalence rates of psychiatric comorbidities were: depressive disorder (44% and 54%), anxiety disorder (20% and 21%), alcohol abuse/dependence (46% and 31%), and narcotic abuse/dependence (18% and 38%). Prescription opioid abusive behaviors were recorded for 24% of VA and 31% of PCC patients. A lifetime history of a substance use disorder (adjusted odds ratio [OR], 3.8; 95% confidence interval [CI], 1.4 to 10.8) and age (adjusted OR, 0.94; 95% CI, 0.89 to 0.99) were independent predictors of prescription opioid abuse behavior.

CONCLUSIONS

A broad spectrum of chronic noncancer pain disorders are treated with opioid medications in primary care settings. The lifetime prevalence of psychiatric comorbidity was substantial in our study population. A significant minority of patients manifested prescription opioid abusive behaviors, and a lifetime history of a substance use disorder and decreasing age were associated with prescription opioid abuse behavior. Prospective studies are needed to determine the potential benefits as well as risks associated with opioid use for chronic noncancer pain in primary care.

Chronic pain prevalence and analgesic prescribing in a general medical population

In order to better understand the prevalence of chronic pain and the frequency of analgesic use in the U.S. veteran general medical population, a review of 300 randomly selected charts was conducted. This review revealed that 50% of patients suffered from at least one type of chronic pain. A review of the corresponding pharmacy records indicated that approximately 75% of patients with chronic pain were prescribed at least 1 analgesic, and most received 2 or more. While nonsteroidal anti-inflammatory drugs were the most commonly prescribed class of analgesics, 44% of those receiving an analgesic received opioids. Examination of clinic notes revealed that the prescribing physicians documented physical examination infrequently, and commented on a specific opioid treatment plan or follow-up of that plan in a minority of cases. It appears that chronic pain is common among U.S. veterans, and that analgesics, including opioids, are commonly prescribed. Documentation of the efficacy of opioids for treating chronic pain is often scant.

Screening for problematic prescription opioid use

The proper medicinal use of opioids, in light of their notorious history and current relation to social ills, continues to be debated and remains unclear in several areas of medicine. This article will review several areas and points of controversy related to screening for potential problematic opioid behavior in chronic nonmalignant pain patients. Controversy over the prescription of opioids for chronic nonmalignant pain continues, despite the growing acceptance of this practice. Indeed, past research supports the beneficial use of opioids for noncancer pain. Unfortunately, traditional definitions of abuse and dependence, with their emphasis on tolerance and withdrawal, are inappropriate for chronic pain patients prescribed opioids. The component of traditional definitions of abuse and dependence that appears most applicable to chronic pain patients centers on the criterion that the patient continue to take the drug (in this case, the opioid) despite negative and harmful effects or despite any decrease in pain level. Although clinical observations exist about risk factors for opioid misuse in chronic pain patients, there is limited research. Further, the area of prescreening for problematic drug behavior is in its infancy. However, researchers have begun to delve into this challenging area and the application of rigorous empirical research will bring us closer to identifying those patients at risk so that their pain is managed without destructive outcomes in other areas of their life.

Behavioral and nonpharmacologic treatments of headache

Cognitive-behavioral analysis and the multiaxial assessment of relevant behavioral domains (headache frequency and severity, analgesic and abortive use and misuse, behavioral and stress-related risk factors, comorbid psychiatric disorders, and degree of overall functional impairment) help set the stage for CBT of headache disorders. Controlled studies of CBTs for migraine, such as biofeedback and relaxation therapy, have a prophylactic efficacy of about 50%, roughly equivalent to propranolol. Cluster headache responds poorly to behavioral treatment. The persistent overuse of symptomatic medication impedes the effectiveness of behavioral and prophylactic medical therapies. Behavioral treatment can help sustain improvement after analgesic withdrawal, however, and prevent relapse in cases of analgesic overuse. Cognitive factors (e.g., an enhanced sense of self-efficacy and internal locus of control) appear to be important mediators of successful behavioral treatment. Patients with CDH are more likely to overuse symptomatic medication (and in some cases abuse analgesics), have more psychiatric comorbidity; have more functional impairment and disability, and are at least as likely to experience stress-related intensification of headache as patients whose episodic headaches occur less than 15 days per month. Despite the significance of these behavioral factors, patients with CDH (particularly those with migrainous features) are less likely to benefit from behavioral treatment without concomitant prophylactic medication than is the case for episodic TTH and migraine sufferers. Continuous daily pain may be more refractory to behavioral treatment as a solo modality than CDH marked by at least some pain-free days or periods of time. The combination of behavioral therapies with prophylactic medication creates a synergistic effect, increasing efficacy beyond either type of treatment alone. Compliance-enhancement techniques, including behavioral contracts for patients with severe personality disorders, can increase adherence to behavioral recommendations. CBT has earned an important place in the comprehensive treatment of patients with episodic migraine/TTH and severe, treatment-resistant chronic daily headache.

Multidisciplinary Treatment of Benign Chronic Pain Syndrome in Substance Abusing Patients

This article presents a model for combined treatment of benign chronic pain and substance abuse. The combined treatment program illustrated draws resources from a comprehensive pain treatment center and an addictions program, which affiliated to better serve these challenging patients. Three illustrative cases are presented. Potentially divisive conceptual issues, such as lack of understanding of the biopsychosocial model of benign chronic pain, and the debate over the role of long-term opioid medication in the treatment of addiction and chronic pain disorders, are discussed.

A pilot survey of aberrant drug-taking attitudes and behaviors in samples of cancer and AIDS patients

The clinical assessment of drug-taking behaviors in medically ill patients with pain is complex and may be hindered by the lack of empirically derived information about such behaviors in particularly medically ill populations. To investigate issues surrounding the assessment of these behaviors, we piloted a questionnaire based on the observations of specialists in pain management and substance abuse. This preliminary questionnaire evaluated medication use, present and past drug abuse, patients' beliefs about the risk of addiction in the context of pain treatment, and aberrant drug-taking attitudes and behaviors. This instrument was piloted in a mixed group of cancer patients (N = 52) and a group of women with HIV/AIDS (N = 111). Reports of past drug use and abuse were more frequent than present reports in both groups. Current aberrant drug-related behaviors were seldom reported, but attitude items revealed that patients would consider engaging in aberrant behaviors, or would possibly excuse them in others, if pain or symptom management were inadequate. Aberrant behaviors and attitudes were endorsed more frequently by the women with HIV/AIDS than by the cancer patients. Patients greatly overestimated the risk of addiction in pain treatment. We discuss the significance of these findings and the need for cautious interpretation given the limitations of the methodology. This early experience suggests that both cancer and HIV/AIDS patients appear to respond in a forthcoming fashion to drug-taking behavior questions and describe attitudes and behaviors that may be highly relevant to the diagnosis and understanding management of substance use among patients with medical illness.

Effect of tramadol and morphine on pain and gastrointestinal motor function in patients with chronic pancreatitis

Tramadol and morphine were compared for treatment of severe chronic pancreatitis pain and their interaction with gut motor function. Oral tramadol or morphine doses were titrated double-blinded and randomized for five days in 25 patients and pain, side effects, bowel function, orocecal and colonic transit, anal resting pressure, and rectal distension thresholds were measured. Pain intensities (mean+/-SD, 0 = none, 100 = unbearable) before treatment and on day 4 were 75+/-19 and 8+/-13 with tramadol (P < 0.001), and 65+/-21 and 5+/-6 with morphine (P < 0.001). On day 4, 67% of patients with tramadol and 20% with morphine rated their analgesia as excellent (P < 0.001) with mean respective doses of 840 mg (range: 80-1920) and 238 mg (20-1125). Orocecal transit was unchanged after five days of tramadol, but increased with morphine (P < 0.05). More patients had prolonged colonic transit times with morphine by day 5 (P < 0.05). Rectal distension threshold pressures increased only with tramadol (P < 0.01). It is concluded tramadol and morphine are potent analgesics in severe chronic pancreatitis pain when individually titrated. Tramadol interfered significantly less with gastrointestinal function and was more often rated as an excellent analgesic than morphine.

Approaches to treatment decisions for psychiatric comorbidity in the management of the chronic pain patient

A number of different types of comorbidities have been described within psychiatric patients. These comorbidity types are reviewed and their application to the chronic pain population is discussed. These various types of comorbidities are then utilized to generate an approach for treatment decisions in the management of the chronic pain patient.

Codeine and oxycodone use in patients with chronic rheumatic disease pain

OBJECTIVE

Opioid treatment of chronic rheumatic disease pain is controversial because of concerns regarding efficacy, toxicity, tolerance, dependence, and abuse. This study examined opioid use in a cohort of patients with pain due to defined rheumatic diseases.

METHODS

Opioid use was studied retrospectively in a cohort of 644 rheumatology clinic patients. Computerized pharmacy records identified patients who had been prescribed opioids during the previous 3 years. Medical records were reviewed to determine reasons for opioid dosage escalations. Patients were interviewed to determine efficacy, frequency and types of side effects, and history of alcohol or street-drug abuse.

RESULTS

Opioid prescriptions were found in the 3-year pharmacy database for 290 of 644 clinic patients: 153 for <3 consecutive months and 137 for > or =3 months. All opioid-treated patients received codeine and/or oxycodone. In this cohort, 133 patients in each opioid-treated group and 76 of the 354 non-opioid-treated control patients were studied. Opioids significantly reduced rheumatic disease pain severity scores from 8.2 to 3.6 (on a 0-10 scale) (P < 0.001). Mild side effects were reported in 38%; nausea, dyspepsia, constipation, and sedation were the most common. The mean +/-SD initial dosage was 2.1+/-1.7 30-mg codeine equivalents/day, the mean peak was 3.4+/-3.3 per day, and the mean current dose was 2.7+/-2.0 per day. Dosage escalations occurred in 32 patients and were attributable to worsening of the underlying painful condition or a medical complication thereof in all but 4 patients, who also displayed other abuse behaviors. Abuse behaviors were not more frequent in those with or without a history of abuse/ addiction.

CONCLUSION

Prolonged treatment of rheumatic disease pain with codeine or oxycodone was effective in reducing pain severity and was associated with only mild toxicity. Doses were stable for prolonged periods of time, with escalations of the opioid dose almost always related to worsening of the painful condition or a complication thereof, rather than the development of tolerance to opioids. Doubts or concerns about opioid efficacy, toxicity, tolerance, and abuse or addiction should no longer be used to justify withholding opioids from patients with well-defined rheumatic disease pain.

The use of nonopioid drugs in management of chronic orofacial pain

Although controversial, opioid analgesics have been prescribed for patients with chronic facial pain. Based primarily on survey data and a few well-controlled clinical trials, long-term opioid treatment provides adequate pain reduction in 41% to 100% of patients with chronic nonmalignant pain. However, only 25% of chronic facial pain patients reported adequate pain relief with chronic opioid treatment. Work, home, and school function are generally reestablished or maintained during chronic opioid treatment, but 25% to 38% of patients remain dysfunctional, and one study indicated that 20% of patients became dysfunctional during treatment. Chronic opioid treatment is associated with many transient side effects; constipation, dizziness, nausea, vomiting, itching, and fatigue have been reported in 5% to 42% of patients taking opioids over 1 year. Although survey studies suggest that the risks of addiction are low in typical patients, drug abuse rates up to 17.3% and prescription abuse rates up to 27.6% were reported within groups of chronic opioid users. Chronic opioid use induces analgesic tolerance and physical dependence, which may result in a serious abstinence syndrome in users and children born to users. Chronic opioid use also may induce harmful immune system changes, diminish cognitive and motor function, and produce nociceptive hyperexcitability. This article shows that the use of long-term opioids for chronic facial pain is not justified based on the available data. Despite these perceived problems, there is anecdotal evidence that chronic facial pain patients will respond positively to opioid analgesics. In our experience, the pain assessment scale and a modification of the World Health Organization's three-step analgesic ladder, which prescribes nonopioid analgesics, can be the starting point for the successful management of chronic facial pain.