Key Point Some preliminary evidence supports off-label use of sublingual buprenorphine for chronic pain, but more research is needed. |
Maintaining a rational, evidence-based approach
Opioid analgesic misuse is a serious public health problem. It would be unfortunate, however, if clinicians were to avoid medically appropriate opioid prescribing for people with chronic pain. Rational, evidence-based strategies to mitigate opioid misuse are the appropriate goal, accompanied by efforts to improve chronic pain treatment with and without opioids. To provide safe and effective opioid therapy, we urge you to develop a proactive approach informed by clinical guidelines, clinical experience, and the scientific literature.
Key Point While opioid analgesic misuse is a serious problem, it would be unfortunate if clinicians avoided prescribing opioids for people in chronic pain. |
Disclosure Dr. Potter receives grant support from the National Institute on Drug Abuse K23 DA02297 (Potter) and U10 DA020024 (Trivedi) and serves as a consultant to Observant LLC. Ms. Marino reported no potential conflict of interest relevant to this article. |
References
- Results from the 2011 National Survey on Drug Use and Health: summary of national findings. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2012. Available at: http://www.samhsa.gov/data/NSDUH.aspx. Accessed December 26, 2012.
- Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician. 2012;15(3 suppl):ES67–E92.
- Manchikanti L, Fellows B, Ailinani H, et al. Therapeutic use, abuse, and nonmedical use of opioids: a ten-year perspective. Pain Physician. 2010;13:401–435.
- Boudreau D, Von Korff M, Rutter CM, et al. Trends in long-term opioid therapy for chronic non-cancer pain. Pharmacoepidemiol Drug Saf. 2009;18:1166–1175.
- Birnbaum HG, White AG, Schiller M, et al. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med. 2011;12:657–667.
- Centers for Disease Control and Prevention. Emergency department visits involving nonmedical use of selected prescription drugs - United States, 2004-2008. MMWR Morb Mortal Wkly Rep. 2010;59:705–734.
- Centers for Disease Control and Prevention. Overdoses of prescription opioid pain relievers - United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487–1492.
- Chou R, Fanciullo GJ, Fine PG, et al. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10:113–130.
- Martell BA, O’Connor PG, Kerns RD, et al. Systematic review: opioid treatment for chronic back pain: prevalence, efficacy, and association with addiction. Ann Intern Med. 2007;146:116–127.
- Butler SF, Budman SH, Fernandez KC, et al. Development and validation of the Current Opioid Misuse Measure. Pain. 2007;130:144–156.
- Katz NP, Adams EH, Chilcoat H, et al. Challenges in the development of prescription opioid abuse-deterrent formulations. Clin J Pain. 2007;23:648–660.
- Diagnostic and Statistical Manual of Mental Disorders, 4th ed., text rev. Washington, DC: American Psychiatric Association, 2000.
- Katz N, Fanciullo GJ. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain. 2002;18(4 suppl):S76–S82.
- Moore TM, Jones T, Browder JH, et al. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med. 2009;10:1426–1433.
- World Health Organization. Cancer: WHO’s pain ladder. Available at: http://www.who.int/cancer/palliative/painladder/en. Accessed December 26, 2012.
- Fine PG, Portenoy RK. Establishing “best practices” for opioid rotation: conclusions of an expert panel. J Pain Symptom Manage. 2009;38:418–425.
- Ballantyne JC, Mao J. Opioid therapy for chronic pain. N Engl J Med. 2003;349:1943–1953.
- Worley J. Prescription drug monitoring programs, a response to doctor shopping: purpose, effectiveness, and directions for future research. Issues Ment Health Nurs. 2012;33:319–328.
- Katz N, Panas L, Kim M, et al. Usefulness of prescription monitoring programs for surveillance—analysis of Schedule II opioid prescription data in Massachusetts, 1996-2006. Pharmacoepidemiol Drug Saf. 2010;19:115–123.
- Simeone R, Holland L. An evaluation of prescription monitoring programs, September 1, 2006. Available at: https://www.bja.gov/publications/pdmpexecsumm.pdf. Accessed December 26, 2012.
- Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician. 2009;12:507–515.
- Jamison RN, Ross EL, Michna E, et al. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain. 2010;150:390–400.
- Potter JS. Co-occurring chronic pain and opioid addiction: is there a role for integrated treatment? Honolulu, HI: American Psychiatric Association Annual Meeting, 2011.
- National Institute on Drug Abuse. Talking to patients about sensitive topics: communication and screening techniques for increasing the reliability of patient self-report. Available at: http://www.drugabuse.gov/nidamed/centers-excellence/resources/talking-to-patients-about-sensitive-topics-communication-screening-techniques-increasing. Accessed January 10, 2013.
- National Institute on Drug Abuse. Managing pain patients who abuse prescription drugs. Available at: http://www.drugabuse.gov/nidamed/etools/managing-pain-patients-who-abuse-prescription-drugs. Accessed January 10, 2013.
- Pergolizzi J, Aloisi AM, Dahan A, et al. Current knowledge of buprenorphine and its unique pharmacological profile. Pain Pract. 2010;10:428–450.
- Park HS, Lee HY, Kim YH, et al. A highly selective kappa-opioid receptor agonist with low addictive potential and dependence liability. Bioorg Med Chem Lett. 2006;16:3609–3613.
- Substance Abuse and Mental Health Services Administration. Diversion and abuse of buprenorphine: a brief assessment of emerging indicators. Final report, 2006. Available at: http://buprenorphine.samhsa.gov. Accessed December 26, 2012.
- Comer SD, Sullivan MA, Vosburg SK, et al. Abuse liability of intravenous buprenorphine/naloxone and buprenorphine alone in buprenorphine-maintained intravenous heroin abusers. Addiction. 2010;105:709–718.
- Malinoff HL, Barkin RL, Wilson G. Sublingual buprenorphine is effective in the treatment of chronic pain syndrome. Am J Ther. 2005;12:379–384.