Prescription Opioid Abuse, Addiction Less Common Than Many Believe
Main Category: Pain / AnestheticsAlso Included In: Alcohol / Addiction / Illegal Drugs; Pharmacy / Pharmacist; Clinical Trials / Drug Trials
Article Date: 17 Jan 2009 - 0:00 PDT
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The abuse and addiction potentials of opioid analgesics prescribed for patients with chronic pain have been of great concern. However, current research indicates that these problems are not as common or widespread as many seem to believe.
In an evidence-based review for Pain Treatment Topics (http://www.Pain-Topics.org), editor Stewart B. Leavitt, MA, PhD, summarizes the findings of major research investigations of these problems. "The research is extensive, but requires careful examination," he notes. "Unfortunately, news media, government agencies, and others have portrayed abuse and addiction associated with prescribed opioids as problems of much larger proportions than seems warranted by the evidence." Several comprehensive investigations support this assertion:
-- In an extensive review, combining results from 24 clinical studies, the overall rate of prescribed opioid analgesic abuse or addiction in patients with pain was about 3.3%. However, fewer than 2 out of 1,000 (0.19%) patients without a current or past substance-use disorder experienced problems with opioids prescribed for pain.
-- Similarly, a clinical investigation of patients receiving daily opioid therapy for chronic noncancer pain prescribed by primary-care physicians found that only 3.7% of patients had a confirmed opioid-use disorder. However, whether or not any of these patients also had prior substance-use problems was not examined.
-- A systematic review, encompassing 17 studies of patients with moderate-to-severe chronic noncancer pain who were treated with opioid analgesics for at least 6 months, found opioid abuse in only 0.4% of patients. Signs of opioid addiction were evident in only 1 case out of 2042 subjects evaluated (0.05%). Whether these extremely low rates were in the overall patient population or solely in those patients without prior substance-use problems is unknown.
Estimates of substance-use disorders among the general public range from 5% to as high as 67%, depending on the population examined; although, the exact percentages of those disorders involving solely opioids has been poorly defined. At the least, it seems fairly certain that the rate of opioid-use problems in patients prescribed those drugs for pain would be no greater than in the population at large, according to Leavitt's review. And, according to other experts, the data suggest that news media accusations of increased opioid abuse being associated with greater numbers of patients being prescribed opioids for chronic pain management are unfounded.
This topic is worthy of further investigation and debate; however, the preponderance of available evidence suggests that establishing medical policies or practices in pain management on a presumption of high rates of prescribed opioid-analgesic abuse or addiction could be misguided, resulting in added costs for healthcare delivery and the undertreatment of pain. Healthcare providers can be reasonably assured that only a very small percentage of their patients with chronic pain, if any, will exhibit abuse/addiction when receiving long-term opioid analgesics. And, this would be especially so in those patients who have not experienced substance-misuse problems in the past.
Pain Treatment Topics and the associated http://www.Pain-Topics.org website provide open and free access to noncommercial, evidence-based clinical news, information, research, and education on the causes and effective treatment of the many types of pain conditions. It is independently produced and currently supported by an unrestricted educational grant from Covidien/Mallinckrodt Inc., St. Louis, MO, a leading manufacturer of generic opioid analgesic products. The sponsor had no participatory role in development of this review.
What are Opioids?
For more information on what opioids are, and opioid-induced constipation (OIC), please see:All About Opioids and Opioid-Induced Constipation (OIC)
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Visitor Opinions In Chronological Order (3)
Too Soon To Tell
posted by Dr Stephen F Grinstead on 19 Jan 2009 at 12:47 pmI was very interested in your posting titled "Prescription Opioid Abuse, Addiction Less Common Than Many Believe." I do in fact agree with some of your observations and findings. However, I do not think your 3.3 to 3.7 percent numbers are an accurate total picture of the extent of the problem.
One reason may be the way problems are screened by different pain management providers. Many of the patients I’ve dealt with over the past 26 years in pain management have a great track record of fooling healthcare professionals. Fortunately, we are getting better at detection and intervention.
The other factor I believe needs to be explored is the rate of prescription medication abuse/addiction when the patient has a personal history or family history of any addictive or mental health disorders.
I have seen many research indicating that the problem is much higher than the rates your research found. In some studies the rates are as high as 40 percent. I myself use a conservative (for me) 10 percent estimate that includes prescription medication abuse, pseudoaddiction, or addiction.
According to researched published in Pain Physician Journal last year; as recently as 2006, 90 percent of people in the US receiving treatment for pain management were prescribed opiate medication. Of that number 9 percent to 41 percent had opiate abuse/addiction problems. The research cited also stated that 16 percent of pain management patients experienced illicit drug use along with their prescribed medication, and as high as 34 percent in other research they reviewed. These numbers give a picture of the overall problem of chronic pain abuse/addiction problems in the general population. What is harder to quantify is the extent of this problem in the recovering community.
Whenever I asked the following question at trainings, “How many of you know someone in long-term recovery who has relapsed over pain management issues?” most of the audience raises their hands. The reasons vary, but more often than not they either take the wrong medication or too much. Others try to tough the pain out and end up relapsing back to their original drug of choice.
Living with chronic pain is difficult for anyone, but especially for someone with coexisting medication abuse, addiction or other psychological disorders. They can become severely depressed and discouraged. Healthcare providers often become confused and frustrated when their treatment interventions are ineffective and frequently blame their patients.
Author's Response To Dr. Grinstead
posted by S. Leavitt MA PhD on 20 Jan 2009 at 3:49 pmThank you, for your comments. Unfortunately, the URL for the full article, which tells much more of the story and is much in agreement with your comments did not appear in the notice. The article can be found in the Pain-Topics 'e-Briefing' newsletter, Vol 3, No 1, 2008 (http://pain-topics.org/pdf/e-Briefing-Vol3-No1-2008.pdf).
Briefly, the prevalence of opioid analgesic-use problems often depends on how they are defined, and the population studied. Rates can be very high or extremely low -- I looked primarily at systematic reviews that attempted to consolidate data from multiple studies in an objective manner.
The prevalence of illicit substance abuse in patients with pain is of great concern, as is noted in the full article. However, these data are also grossly confounded by marijuana use, without examining motivations (eg, for therapeutic vs recreational use).
As Dr. Grinstead observes, relapse in persons with addictive or mental disorders being treated for pain is a frustrating problem. However, as is acknowledged, this can be provoked by undertreated pain and associated misuse of medication for pain relief, rather than a true reversion to prior addictive behaviors.
These are all subjects worthy of much more discussion and debate. And, while the problems are quite serious, the data do not signal that they are of the monumental proportions depicted in some biased studies and the news media.
Dr. won't listen!
posted by Nancy on 1 Feb 2011 at 5:13 pmI have RSD, and for 7 yrs, have argued with my Dr., about my meds, I've had every kind of treatment, shots, stimulator, therapy, been there. He is worried about over prescribing, and not listening to me. It's like pulling teeth to get a change of meds at all. He just doesn't want to do it. I am at my wits end, in the fall and winter I end up in the E.R. getting shots because the pain is so great, and he just doesn't see the forest for the trees, I live in a VERY small community. What would be some ,any suggestions for me?
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