Opioids have become the standard of care for numerous chronic pain complaints and are the most misused drugs in the United States.1 The result: A public health issue with challenges for patients with pain, clinicians treating pain, and the broader community. (See “Opioid analgesic misuse: Scope of the problem,” below1-7).
Ultimately, clinicians are faced with trying to provide adequate pain relief while predicting which patients are at risk for misuse. An expert panel commissioned by the American Pain Society and American Academy of Pain Medicine (APS/AAPM) reviewed the evidence and issued clinical guidelines for long-term opioid therapy in chronic noncancer pain.8 Using the APS/AAPM framework, this article discusses how to:
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identify the risk of problem use in the individual patient
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monitor opioid therapy to ensure safe prescribing
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determine when to terminate opioid therapy in cases of opioid misuse.
| OPIOID ANALGESIC MISUSE: SCOPE OF THE PROBLEM Americans consume an estimated 80% of the global supply of prescription opioids.2 From 1997 to 2007, average sales of opioid analgesics per person increased 402%.3 Because opioid analgesics are increasingly available in the community,4 the prevalence of opioid misuse has followed suit. Opioid analgesics have become the most misused drug class in the United States—second only to marijuana among all illicit substances.1 Nonmedical users of opioid analgesics numbered 4.5 million in 2011, and 1.8 million opioid analgesic users met diagnostic criteria for dependence or abuse.1 In 2007, the costs to society of opioid analgesic abuse were estimated at $25.6 billion due to lost productivity, $25.9 billion due to health care costs, and $5.1 billion due to criminal justice costs, totaling $55.7 billion.5 Regardless of whether opioid analgesics are obtained by prescription or diversion (sharing medication, stolen, or purchased illegally), their misuse in all its forms is a significant public health problem. Opioid analgesic–related emergency department visits increased 111% from 2004 to 2008, to a total of 305,900 visits.6 Deaths involving opioid analgesics, including intentional and unintentional overdoses, quadrupled from 1999 to 2008.7 Additionally, from 1999 to 2009, national admission rates for treatment of an opioid analgesic–related substance use disorder increased nearly sixfold.7 |
Before treatment: Determine misuse risk
Despite their widespread use, long-term opioid analgesics are not recommended as first-choice therapy.8 Evidence supporting long-term efficacy is limited, and studies indicate modest clinical effectiveness.9 Concerns also are emerging about the safety of long-term opioid use, including iatrogenic opioid-related substance use disorders. Even categorizing opioid misuse is difficult because consensus is lacking on misuse terminology (TABLE 1).8,10-12
On the other hand, many patients with chronic pain do benefit from opioid analgesics, and most who are prescribed long-term opioid therapy do not misuse their medications. The use of opioid analgesics for chronic pain presents an opportunity for misuse in a subset of susceptible people.
| Key Point The use of opioid analgesics for chronic pain presents an opportunity for misuse in a subset of susceptible people. |
TABLE 1
Glossary of of opioid use terminology
| DSM, Diagnostic and Statistical Manual of Mental Disorders. |
| Aberrant drug-related behavior Opioid-related behavior that demonstrates nonadherence to the patient-clinician agreed-upon therapeutic plan8 |
| Misuse Use of an opioid in a manner other than how it is prescribed10,11 |
Abuse Illicit opioid use that is detrimental to the user or others10 Nonmedical use of an opioid for the purpose of attaining a “high”11 A DSM-IV-TR substance use disorder diagnosis, evidenced by a maladaptive pattern of opioid use, leading to clinically significant impairment or distress as manifested by ≥1 of the following criteria in a 12-month period:
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Dependence A DSM-IV-TR substance use disorder diagnosis, evidenced by a maladaptive pattern of opioid use, leading to clinically significant impairment or distress as manifested by ≥3 of the following criteria in a 12-month period:
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Risk factors thought to increase susceptibility include younger age, more severe pain intensity, multiple pain complaints, history of a substance use disorder, and history of a psychiatric disorder.2 Identifying individuals with potential for misuse is difficult, however, and clinicians’ attempts are not necessarily accurate.13