).6 To clarify interpretation, the Liaison Committee on Pain and Addiction of the American Society of Addiction Medicine (ASAM) has provided an outline of possible indicators of addiction in pain patients (Table 4).6 This was a consensus statement from the American Pain Society, the American Academy of Pain Medicine, and ASAM.
Assessment is primarily clinical and requires an awareness of appropriate terminology, an index of clinical suspicion, and expertise teasing apart pain, addiction, and pseudoaddiction. In our experience, it is helpful to ask a chronic pain patient whom you suspect might have POUD, “Have you ever used your prescribed opioids for reasons other than improving function or reducing pain, such as for getting a ‘high,’ managing stress, escaping from problems, etc.?” An affirmative response suggests an underlying problem with use of prescribed opioids, indicating a need for more careful questioning to determine if AMTBs or POUD coexist with chronic pain.
Drug testing can help determine if a patient is taking opioids that are not prescribed—as well as illicit drugs or alcohol—and confirm the presence of those that are prescribed. Toxicology screening should include opioids typically screened for (eg, morphine, codeine, heroin) and those for which additional tests may be required (eg, semi-synthetics such as oxycodone and hydrocodone and synthetics such as fentanyl).
Table 3
Identifying addiction in pain patients: Limitations of DSM-IV-TR
| DSM-IV-TR substance dependence criteria | Challenges in using criterion to diagnose prescription opioid use disorder |
|---|---|
| Tolerance | Expected with prolonged opioid compliance |
| Physical dependence, withdrawal | Expected with prolonged opioid compliance |
| Use of larger amounts or longer than initially intended | Emergence of pain may demand increased dose or prolonged use |
| Multiple failed attempts to cut down or control | Emergence of pain may deter dose reduction or cessation |
| Time spent finding, using, or recovering | Difficulty finding adequate pain treatment may increase time spent pursuing analgesics. However, time spent recovering from overuse may suggest addiction |
| Given up or reduced important activities | Valid criteria—engaging in activities is expected to increase, not decline, with effective pain treatment |
| Continued use despite knowledge of negative consequences | Valid criteria—no harm is anticipated from analgesic opioid use for pain (see Table 4) |
| Source: Adapted from reference 6 | |
Table 4
Possible indicators of addiction in pain patients
| ASAM-APS-AAPM behavioral criteria | Examples of specific behaviors in opioid therapy for pain |
|---|---|
| Impaired control over opioid use | Patient requests early refills, frequently reports loss or theft of medication. Withdrawal noted at follow-up appointments despite having an adequate quantity of medication prescribed |
| Continued use despite harm from opioids | Patient exhibits declining function, opioid intoxication, persistent oversedation from opioids |
| Preoccupation with opioids | Patient ignores non-opioid interventions for pain, makes recurrent requests for opioid dose escalation (or complains of increasing pain) despite absence of disease progression or despite opioid dose increase by provider |
| AAPM: American Academy of Pain Medicine; APS: American Pain Society; ASAM: American Society of Addiction Medicine Source: Adapted from reference 6 | |
Helping POUD patients
Goals of treatment include establishing a therapeutic alliance, educating patients about POUD, reducing relapse risk, and optimizing overall health (including pain and physical function). The ASAM Patient Placement Criteria22 provide guidance regarding level-of-care decisions. Treatment ideally includes a combination of education about POUD and its relationship to chronic pain, pharmacotherapy, psychotherapy—such as motivational enhancement therapy, 12-step facilitation therapy, cognitive-behavioral therapy, and relapse prevention—and referral to self-help groups such as Narcotics Anonymous or Pills Anonymous. Importantly, if pain is genuine, it requires treatment.
Pharmacotherapy. Methadone is recommended as the standard of care for OUD by the National Institutes of Health. Methadone is a full opioid agonist that decreases illicit opioid use, mortality, and related problems and requires highly structured treatment approaches under federal and state regulation. POUD patients may have higher rates of methadone maintenance treatment retention than heroin-dependent patients.23 Published trials of buprenorphine for OUD have shown good treatment retention and reduction in illicit drug use and adverse events.24 Buprenorphine also decreases mortality among OUD patients.
The first large-scale, randomized clinical trial of buprenorphine specifically for POUD included 653 treatment-seeking outpatients.25 This study was designed to approximate clinical practice and included buprenorphine/naloxone, recommended abstinence, and self-help; one-half of participants received intensive addiction counseling. POUD patients were most likely to reduce prescription opioid misuse during buprenorphine/naloxone treatment. If tapered off buprenorphine/naloxone, even after 12 weeks of treatment, the likelihood of an unsuccessful outcome was high. Moreover, opioid dependence counseling did not seem to afford any difference in outcomes. However, despite clinical effectiveness, over the last decade only 19% of patients admitted primarily for OUD treatment (other than heroin) were planned to be offered buprenorphine or methadone.26