Assessing the Misuse and Abuse of Opioids

Orlando—Five years ago, David Fishbain, MD, and co-authors published an article in Pain Medicine that examined issues related to opioids. They conducted an evidence-based review of 2507 patients with chronic pain who participated in 24 trials [2008;9(4):444-459].

During a 26-month period, 3.27% of the patients abused or became addicted to the drugs. In addition, of the patients who had not previously abused or were addicted to medications, 0.19% ended up abusing the drugs. The authors concluded that 4.35% of first-time chronic opioid users would develop an addiction.

Dr. Fishbain, a professor of psychiatry at the University of Miami who spoke at the AAPM meeting, noted the study was an incidence trial and should not be compared with a prevalence study, a meta-analysis, or a statistical analysis.

Still, he noted that other studies have indicated the increasing opioid-related problems, although it is still difficult to assess pain and prescribe the right medications.

In May, the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), an update from the fourth edition released in 2000. Dr. Fishbain said that the definitions from DSM-4 did not have much reliability and validity for patients who take opioids to treat chronic pain.

In DSM-5, the criteria for determining an opioid use disorder includes a maladaptive pattern of substance use leading to clinically significant impairment impairment or distress and having 2 or more of the following in a 12-month period: taking a larger dose of opioids over a longer period of time than was prescribed; persistent desire or unsuccessful efforts to control use; spending a large amount of time on obtaining, using, or recovering opioids; craving for opioids; failing to fulfill work, home, or school obligations; continuing to take opioids after experiencing social or interpersonal problems; reducing or stopping activities because of opioid use; using opioids in physically hazardous situations; and continuing to use despite persistent physical or psychological problems related to opioids.

Dr. Fishbain said the DSM-5 criteria “isn’t much of an improvement” compared with DSM-4. He predicted that the new criteria will lead to too many opioid use disorder diagnoses.

A better definition of an addiction, according to Dr. Fishbain, comes from the American Academy of Pain Medicine, American Pain Society, and American Society of Addiction Medicine. Those organizations consider addiction a primary, chronic, neurobiological disease influenced by genetic, psychosocial, and environmental factors. People with addiction have 1 or more of the following behaviors: impaired control over their drug use, compulsive use of the drug, continued use despite harm, and a craving for the drug.

Dr. Fishbain cited studies from the Clinical Journal of Pain [2002;18:528-538 and 2001;17:220-228] that found potential risk factors for addiction included biological parents or family members abusing drugs, spending time around people who use drugs, smoking, and illicit drug or alcohol use. Other, less predictive risk factors from those studies included gambling, behavioral problems as a child, lower socioeconomic status, biological parents have an antisocial personality, being the child of a divorce or having a single-parent household, and having comorbid depression, antisocial personality disorder, and an anxiety disorder. Further, the following risk factors have been associated with addiction: impulsivity, multiple physical traumas, compulsive behavior, high neuroticism, and high extraversion.

Research has also indicated a correlation between aberrant drug-related behaviors (ADRBs) and the development of opioid dependence, according to Dr. Fishbain. He mentioned a study from the Journal of Pain and Symptom Management [1996;14:203-217], the Substance Abuse: A Comprehensive Textbook from 1992, and a presentation from June 2002 at the International Conference on Pain & Chemical Dependency. Some of the ADRBs cited include having multiple dose escalations or noncompliance despite warnings, multiple episodes of prescription losses, attempts to get prescriptions from providers or the emergency room without telling the primary prescriber, a deterioration in the ability to work or interact with family or in social situations, and a resistance to changing therapies despite being told about adverse physical or psychological issues.

Other ADRBs associated with opioid dependence included selling prescription drugs, forging prescriptions, stealing drugs, injecting oral formulations, obtaining drugs from nonmedical sources, and concurrently abusing alcohol or illicit drugs. The following ADRBs were less predictive of developing opioid dependence: aggressive complaining for more drugs, drug hoarding, requesting specific drugs, unsanctioned dose escalation or noncompliance on 1 or 2 occasions, unapproved use of drugs to treat another symptom, reporting psychic effects not intended by a clinicians, and resistance to a change in therapy associated with tolerable side effects.

Still, Dr. Fishbain said providers have a difficult time if patients are engaging in ADRBs based only on their interactions. In an article he authored in Pain Medicine, Dr. Fishbain found 11.5% of patients had ADRBs [2008;9(4):444-459]. However, when providers used urine drug monitoring to detect use, they found that 20.4% of patients displayed ADRBs.

Dr. Fishbain also discussed an article in the Psychiatric Times that differentiated pseudo-addiction from addiction [2003;20:25-27]. Patients with a pseudo-addiction do not escalate their dose when their pain is under control, do not try to achieve euphoria, do not have signs of intoxication, focus on side effects associated with the drugs, and follow recommendations for other forms of treatment. Meanwhile, patients with an addiction continue escalating their drug dosage, try to reach a state of euphoria, show signs of intoxication such as sedation or confusion, do not think about side effects of drugs, and do not follow recommendations regarding other therapeutic options.

According to Dr. Fishbain, there are several potential ways to determine if patients with chronic pain will develop a dependence on opioid analgesics, including if they are unwilling to taper opioid use when offered other treatment options, if they do not experience relief from other therapies, and if they display some ADRBs.

Several tools have been developed to assess potential ADRBs and potential for opioid abuse. They include the Screener and Opioid Assessment for Patients with Pain, the Opioid Risk Tool, the Diagnosis, Intractability, Risk, Efficacy tool, the Prescription Drug Use Questionnaire, and the Current Opioid Misuse Measure. Although they vary in terms of the format and number of questions, the topics covered include evaluating risk and asking about any personal or family history with substance abuse, sexual abuse, psychiatric illness, legal troubles, or anger issues.