Evidence-Based Reviews

Prescription opioid use disorder: A complex clinical challenge

Current Psychiatry. 2012 August;11(8):14-22

Shannon C. Miller, MD

Fasam, FAPA

Ctts

Understanding patients’ aberrant medication-taking behaviors can greatly aid treatment

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References

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Discuss this article at www.facebook.com/CurrentPsychiatry

You’ve been treating Mr. H, a 54-year-old factory worker and tobacco user, for depression that developed after a work-related back injury and subsequent disability. His depression has had a fair response to an antidepressant. He also has been maintained on chronic opioids (morphine and oxycodone/acetaminophen) for 18 months by his primary care physician (PCP). At the end of your appointment, he asks you for a refill of the opioids because he “ran out” early because of increased night pain and resultant insomnia and “stress.” He clarifies he has asked for early refills before from his PCP, but lately he has been denied. Because you “seem to listen to me more,” he asks for your help. How should you manage Mr. H?

Opioids are among the most commonly misused prescription drugs in the United States.¹ In 2008, poisoning was the leading cause of death from injury in the United States; roughly 90% of poisonings resulted from drug exposure, and >40% of these drug poisonings were from prescription opioids.² The Centers for Disease Control and Prevention estimates that the number of emergency department (ED) visits for nonmedical use of opioids increased 111% between 2004 and 2008, from 144,600 to 305,900 visits.³ The highest number of visits were for use of oxycodone, hydrocodone, and methadone.³

Increased prescribing of opioids and overdose deaths attributable to prescribed opioids have raised concern among physicians about how to effectively treat pain as well as prevent, recognize, and manage aberrant medication-taking behaviors (AMTBs). Psychiatrists are well-positioned to screen and manage their own patients for prescription opioid use disorder (POUD) or collaborate with opioid prescribers to accomplish the same.

Clarifying terminology

Terminology used to describe POUD and related conditions often is poorly defined or loosely applied. Because emotions often enter discussions between patients and physicians about problems related to opioid therapy, nonstigmatizing and more objective terminology is needed, and clinicians are working toward standardizing this. Relevant terms are defined in Table 1.⁴

The DSM-5 Substance Use Disorders Work Group has proposed using the term opioid use disorder (OUD) to replace the term opioid dependence.⁵ The hope is that removing the word “dependence” from the diagnostic term will reduce confusion between “dependence” due to expected physical dependence (tolerance, withdrawal) on medically prescribed opioids vs true addiction (currently defined as “opioid dependence” in DSM-IV-TR). This Work Group also has proposed combining opioid abuse and opioid dependence criteria into a single diagnosis of OUD, and adding “craving” to the criteria. For the complete proposed criteria, see www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=460.These changes are still under review. In this article, we use the term POUD.

Table 1

Terminology related to prescription opioid use disorder

Term	Definition
Chronic pain^a	Pain that extends beyond the expected period for healing (6 months), initiated by tissue damage, but perpetrated by the interaction of physiologic, affective, and environmental factors
Chronic nonmalignant pain^a	Chronic pain associated with diverse diagnoses and syndromes that are not terminal but affect the patient’s function
Appropriate use^a	Taking a prescription as prescribed, and only for the condition indicated
Misuse^a	Taking a prescription for a reason or at a dose or frequency other than for which it was prescribed; this may or may not reflect POUD
Drug-seeking behaviors	Patient behaviors directed toward obtaining controlled substances, driven not by amelioration of the condition for which the medication was indicated but rather by other maladaptive gains; this may or may not reflect POUD
Chemical coping	Taking a controlled substance medication to relieve psychological problems (eg, to relieve low mood, anxiety, insomnia) and for reasons other than the purpose for which it was prescribed; this may or may not reflect POUD
Aberrant medication-taking behaviors^a	Taking a controlled substance medication in a manner that is not prescribed; causes for this may include: lack of understanding about how to take the opioid appropriately external pressures, such as to give to another person for his or her pain chemical coping pseudoaddiction (see below), including: addiction or substance use disorder (such as POUD) diversion
Pseudoaddiction	An iatrogenic syndrome of “addiction-like” behaviors in which the patient seeks opioids to relieve pain—such as seeking different doctors, self-adjusting the opioid dose, early refills of opioids, etc.—rather than to achieve pleasure or other nonpain-related effect. At times mistaken for true addiction, these behaviors tend to resolve and function improves once analgesia is better addressed
^a These terms and definitions are adapted from reference 4. The remaining terms and definitions were developed by the authors POUD: prescription opioid use disorder

POUD and chronic pain

The incidence of POUD during opioid therapy for pain is unknown.⁶ Some researchers have suggested it may be as low as 0.2%,⁷ while others estimate that rates of POUD in patients with chronic pain may be similar to those in the general population: 3% to 16%.⁸ When applying the proposed DSM-5 criteria to patients receiving long-term opioid therapy for noncancer pain, the lifetime prevalence of POUD may be as high as 35%.⁹