ABSTRACT: Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of these drugs is prominent in patients with chronic pain. Recognition and early prevention of misuse helps physicians identify the causes and proceed with patient care. Most persons with chronic pain have a significant medical comorbidity (eg, asthma) that affects treatment decisions. All patients should undergo an initial comprehensive evaluation. Patients often have a psychiatric comorbidity, such as depression or anxiety. There is no gold standard for risk assessment, but several traditional measures may be used. Pain medicine practitioners increasingly are using urine drug screens to monitor adherence to long-term opioid therapy. Controlled substance agreements help improve patient compliance. ( 2008;25:268-277, 302)
Chronic pain is a costly problem that influences every aspect of a person's quality of life, interfering significantly with sleep, employment, social functioning, and activities of daily living. Patients often report depression, anxiety, irritability, sexual dysfunction, and decreased energy. Family roles are altered, and worries about financial limitations and the consequences of a restricted lifestyle abound.1-5
Epidemiological studies have independently documented that chronic pain is seen as an immense problem worldwide.6-8 Symptoms affect more than 90 million Americans—about one-third of the US population. Chronic pain accounts for 21% of emergency department visits and 25% of annual missed workdays. Including both direct and indirect costs, chronic pain is responsible for up to $100 billion in annual costs, imposing the greatest economic burden of any condition.9-12
Several studies have confirmed that opioid analgesics are useful for managing acute and cancer related pain.13 They also are considered effective treatment for persons with chronic noncancer pain and are known to have a similar safety advantage to that of long-term therapy with NSAIDs. However, many physicians are reluctant to support the use of opioids in these patients because they have concerns about adverse effects, tolerance, and addiction.
Epidemiological data from the National Comorbidity Survey of Psychiatric Disorders in the United States indicate a lifetime prevalence of 7.5% for drug dependence (illicit or prescription drugs) and 14.1% for alcohol(Drug information on alcohol) dependence.14 About 3% of Americans 18 years or older meet the criteria for illicit drug abuse or dependence as defined by the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV).15 In a sample of 363 hospitalized patients, 21.8% had a current addiction to alcohol or illicit drugs.16
Prescription opioid analgesics are said to be the most frequently abused drugs in the United States, and misuse is prominent in patients with chronic pain. In a literature review, Strain17 reported that 15% to 23% of patients with chronic pain met the criteria for a substance abuse disorder.
Recognition and early prevention of substance misuse helps physicians treating patients with chronic pain identify the causes and sources and proceed with legitimate medical practice and patient care.18 Assessment and treatment protocols are needed to determine the potential for abuse when opioids are prescribed and to manage any misuse behaviors. These protocols provide physicians with a better understanding of the patient's background and behavior and help patients who show signs of medication misuse remain compliant when taking opioids for pain.
In this article, we discuss the opioid abuse and misuse issues that often arise in the treatment of patients with chronic noncancer pain and describe assessment and treatment strategies.A case report is offered to illustrate the key points (see the Box, "Case study: At risk for medication misuse," below.