Evidence-Based Reviews

Prescription opioid use disorder: A complex clinical challenge

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

References

1. U.S. Department of Health and Human Services. Substance Abuse and Mental Health Services Administration. Office of Applied Studies. Results from the 2009 national survey on drug use and health: volume I. http://www.samhsa.gov/data/NSDUH/2k9NSDUH/2k9Results.htm. Accessed June 20, 2012.

2. Warner M, Chen LH, Makuc DM, et al. Drug poisoning deaths in the United States, 1980-2008. http://www.cdc.gov/nchs/data/databriefs/db81.htm. Published December 2011. Accessed June 20, 2012.

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5. American Psychiatric Association. R 19 opioid use disorder. http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=460. Updated April 30 2012. Accessed June 20, 2012.

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7. Fishbain DA, Cole B, Lewis J, et al. What percentage of chronic nonmalignant pain patients exposed to chronic opioid analgesic therapy develop abuse/addiction and/or aberrant drug-related behaviors? A structured evidence-based review. Pain Med. 2008;9(4):444-459.

8. Gourlay DL, Heit HA. Pain and addiction: managing risk through comprehensive care. J Addict Dis. 2008;27(3):23-30.

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14. Butler SF, Budman SH, Fernandez KC, et al. Cross-validation of a Screener to Predict Opioid Misuse in Chronic Pain Patients (SOAPP-R). J Addict Med. 2009;3(2):66-73.

15. Passik SD, Kirsh KL, Casper D. Addiction-related assessment tools and pain management: instruments for screening treatment planning, and monitoring compliance. Pain Med. 2008;9(suppl 2):S145-S166.

16. Chou R, Fanciullo GJ, Fine PG, et al. Opioids for chronic noncancer pain: prediction and identification of aberrant drug-related behaviors: a review of the evidence for an American Pain Society and American Academy of Pain Medicine clinical practice guideline. J Pain. 2009;10(2):131-146.

17. Alford DP, Liebschutz J, Jackson A, et al. Prescription drug abuse: an introduction. http://www.drugabuse.gov/sites/default/files/prescription-drug-abuse-alt.pdf. Published November 8, 2009. Accessed June 20, 2012.

18. Passik SD, Kirsh KL, Whitcomb L, et al. Monitoring outcomes during long-term opioid therapy for noncancer pain: results with the Pain Assessment and Documentation Tool. J Opioid Manag. 2005;1(5):257-266.

19. Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432-442.

20. Passik SD. Pain management misstatements: ceiling effects red and yellow flags. Pain Med. 2006;7(1):76-77.

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23. Banta-Green CJ, Maynard C, Koepsell TD, et al. Retention in methadone maintenance drug treatment for prescription-type opioid primary users compared to heroin users. Addiction. 2009;104(5):775-783.

24. Moore BA, Fiellin DA, Barry DT, et al. Primary care office-based buprenorphine treatment: comparison of heroin and prescription opioid dependent patients. J Gen Intern Med. 2007;22(4):527-530.

25. Weiss RD, Potter JS, Fiellin DA, et al. Adjunctive counseling during brief and extended buprenorphine-naloxone treatment for prescription opioid dependence: a 2-phase randomized controlled trial. Arch Gen Psychiatry. 2011;68(12):1238-1246.

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27. Minozzi S, Amato L, Vecchi S, et al. Oral naltrexone maintenance treatment for opioid dependence. Cochrane Database Syst Rev. 2011;(4):CD001333.-

A Cochrane review of oral naltrexone for OUD found that the drug was no better than placebo but concluded that available evidence does not allow an adequate evaluation.²⁷ Opioid antagonists may be of value to patients who do not want to take agonists or partial agonists. Extended-release naltrexone also is available to treat OUD.

See the Box below that details steps the FDA and others have taken to prevent POUD and Table 5 for precautions to incorporate when prescribing opioids long-term.

Box

Taking steps to prevent prescription opioid use disorder

The FDA has moved toward a risk evaluation and mitigation strategy (REMS) for opioids prescribed for pain that requires clinicians to receive training and certification in prescribing opioids for pain as well as identifying and reducing the risk for prescription opioid use disorder (POUD).a In 2011, the Obama administration developed an action plan to better address prescription drug abuse that required several federal agencies to develop programs and policies to address this growing problem; this plan was updated for 2012 (the complete National Drug Control Strategy 2012 is available at www.whitehouse.gov/sites/default/files/ondcp/2012_ndcs.pdf). The American Society of Addiction Medicine has issued a public policy statement that supports the federal approach and outlines other means to reduce POUD.^b

Some pain specialists recommend requiring patients to sign an Opioid Pain Management Agreement that includes an “exit strategy” before the first opioid prescription is written. These agreements incorporate elements of “universal precautions” to take when prescribing opioids long term.c,d Although not well-studied, prescribing agreements may help educate patients and providers on how to interact in the management of pain with opioids in a way that is objective and empathic, and may reduce POUD risk.

References

U.S. Department of Health and Human Services. U.S. Food and Drug Administration. Opioid drugs and risk evaluation and mitigation strategies (REMS). http://www.fda.gov/drugs/drugsafety/informationbydrugclass/ucm163647.htm. Updated April 5, 2012. Accessed June 28, 2012.
American Society of Addiction Medicine. Measures to counteract prescription drug diversion, misuse and addiction. http://www.asam.org/advocacy/find-a-policy-statement/view-policy-statement/public-policy-statements/2012/01/26/measures-to-counteract-prescription-drug-diversion-misuse-and-addiction. Published January 25, 2012. Accessed June 20, 2012.
Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112.
Gourlay DL, Heit HA. Universal precautions revisited: managing the inherited pain patient. Pain Med. 2009; 10(suppl 2):S115-S123.

Table 5

Universal precautions with chronic opioid management

Goals of therapy: partial pain relief and improvement in physical, emotional, and/or social functioning
Requirement for a single prescribing provider or treatment team
Limitation on dose and number of prescribed medications
Prohibition of changing dosage without discussion with the provider first
Monitoring patient adherence; discuss the use of ‘pill counts’
Prohibition of use with alcohol, other sedating medications, or illegal drugs without discussion with the provider
Agreement not to drive or operate heavy machinery until abatement of medication-related drowsiness
Responsibility to keep medication safe and secure
Prohibition of selling, lending, sharing, or giving medication to others
Limitations on refills—only by appointment, in person, and no extra refills for running out early
Compliance with all components of overall treatment plan (including consultations and referrals)
Biological testing to screen for drugs of abuse or alcohol as well as to confirm the presence of prescribed opioids
Adverse effects and safety issues, such as the risk of physical dependence and addiction behaviors
The option of sharing information with family members and other providers, as necessary, with the patient’s consent
Need for periodic reevaluation of treatment
Reasons for stopping opioid therapy
Consequences of nonadherence with the treatment agreement
Source: Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med. 2005;6(2):107-112.

CASE CONTINUED: A closer evaluation

After expressing your appreciation for Mr. H’s kind words and empathy for his chronic pain, you redirect him to his PCP. You ask him to sign a release of information so you and his other clinicians can coordinate his care. When discussing Mr. H with his PCP, you learn the patient has made limited requests for early refills and dose escalation primarily in relation to inadequate pain control and function, has genuine pain pathology, and is greatly distressed over his inability to work. No other AMTBs are present, and a check of the state prescribing database reveals that Mr. H did receive a small quantity of opioids from an ED on 1 occasion.

You and Mr. H’s PCP agree this is “pseudo-addiction” but want to watch Mr. H more closely and look for ways to coordinate his care. The PCP agrees to implement a prescribing agreement, start drug testing (including for the prescribed opioids), and reassess maximizing Mr. H’s function and pain management while you address his combined pain, depression, insomnia, and tobacco use.