Dependence on Prescription Opioids – Apr 2006 – Free full-text PMC article
This PubMed article describes “opioid dependence” as it is currently (and wrongly) defined in the ICD-10. This version of the standard diagnoses and billing manual has created a linear model of opioid “use disorder” (as though any use at all were a disorder).
This model relates the severity of the “disorder” to the frequency and amount of use, vilifies normal medication side-effects, and confuses symptoms of chronic pain with symptoms of opioid addiction.
It completely ignores the critical distinction between dependence and addiction, which results in a strange paradox:
- If a person has chronic pain and is on high daily doses of prescribed opioids for a long time, they can be labeled as highly “dependent”, though the description of this state is clearly that of addiction.
- If a person indulges in the recreational use of illegal opioids and takes them to get high every few days, they can be labeled as less “dependent”, which makes their situation seem less disordered than that of most chronic pain patients.
Strategies to prevent prescription opioid dependence include:
- Educating and counseling patients
- Using the correct indications for treatment with regular indication review
- Early identification of patients at risk and risk-taking behavior.
When is opioid therapy indicated for chronic non-cancer pain?
For most chronic non-cancer pain, the LONTS guidelines give an open recommendation. This means that, although opioids may be used, there are currently no high quality studies for proof of efficacy. For instance, for chronic back pain, therapy should be time-limited (<3 months), with an eventual extension upon good response
Even if a patient responds well to treatment, an attempt to stop therapy after six months should be made for re-evaluation.
Putting aside the questionable judgment to terminate a well-working therapy “just because”, these universal limits, like 6 months, are absurd. They would apply equally to
- a severe burn victim who may be hospitalized and suffer excruciatingly painful treatments for years
- a person who has mild pain but expects medication to give 100% relief
Contraindications to opioid therapy
Opioids are contraindicated for:
- Primary headaches
- Pain from functional disorders of organ systems, such as irritable bowel syndrome
- Fibromyalgia syndrome (with the exception of tramadol, which presumably works as a serotonin-norepinephrine reuptake inhibitor)
- Chronic pain due to a mental disorder (for example, post-traumatic stress disorder, atypical depression, or generalized anxiety disorder)
Who is allowed to decide that a patient’s pain is due to a mental disorder?
This specifically encourages all currently undiagnosed pain (true diagnoses can take years) to be viewed as a mental problem, and thus virtually instructs doctors to believe and diagnose any pain of unknown origin as “all in your head”.
- Inflammatory bowel disease or chronic pancreatitis (with the exception of acute episodes or a therapy shorter than 4 weeks)
- Comorbidity of severe mood disorders and/or suicidal behavior
- Irresponsible use of medicines
- Women who are pregnant or are planning pregnancy
Dependence: The perceived effects of using a substance are so positive that it leads to loss of control of its use.
WRONG, WRONG, WRONG!
This is the definition of ADDICTION.
Dependence is a purely physical phenomenon.
Dependence has nothing to do with the desirability of or craving for a substance or “loss of control”.
Unfortunately, the ICD-10 definition of addiction has muddied the waters between dependence (physical) and addiction (mental).
Dependence is defined by ICD-10 as the existence of more than three of the following criteria in 12 months:
- loss of control with respect to use, [related to lack of control over pain flares?]
- craving, [craving pain relief?]
- withdrawal symptoms, [also from non-opioids, like antidepressants and caffeine]
- development of tolerance with dose escalation, [also from non-opioids, like antidepressants and caffeine]
- neglect of alternative interests, [because they become too painful?] and
- continued use despite negative consequences [like constipation?].
These symptoms of addiction are now applied to pain patients using opioids for pain relief.
Only withdrawal and tolerance are applicable to a normal physical dependence on opioids.
The same tolerance and nasty withdrawals happen with most other non-opioid medications prescribed for pain in place of opioids, like antidepressants, antiepileptics, mood stabilizers, and even caffeine.
Harmful use: According to ICD-10, harmful use causes actual damage to the mental or physical health of the consumer. This is possibly more difficult to detect for opioid abuse than for nicotine or alcohol.
Taking opioids to relieve constant severe pain is “beneficial use”, not “harmful use”.
Misuse: Using a substance with another intention than the originally intended one based on indications is misuse. An example is using opioids for inducing sleep, euphoria, or pleasure.
Pain patients do not experience the euphoria sought by opioid “abusers”, so there is little motivation to use them besides pain relief.
Pseudoaddiction: Patients who suffer from pain but are not adequately treated can have behavior patterns that mimic an addiction. This can occur, for example, if the half-life of the used substances have not been taken into account, or if postoperative opioids are used “sparingly.
Tolerance development: Tolerance is developed by a compensatory reduction in the number and sensitivity of the central nervous system receptors. Development of tolerance is slower for the analgesic effects than for the euphoric effects of opioids.
Potential for abuse: The potential for abuse of a substance depends on a rapid onset of action and its euphoric effect. For instance, oxycodone has a higher abuse potential than morphine, and immediate-release formulations have a higher abuse potential than extended-release formulations. However, the speed of onset of action can also be influenced, for instance if an extended-release tablet is crushed.
Abuse and addiction
Opioid dependence is highly stressful for the patient and, in the worst case, could lead to a fatal overdose
Pain is by definition one of the most stressful sensations possible.
Opioid-dependent patients often request dose increases that cannot be explained by the normal development of tolerance by pain patients.
Often? Here they even admit that the development of tolerance is “normal”.
According to the LONTS guidelines, a daily dose for chronic non-cancer pain should normally not exceed 120 mg of oral morphine equivalents, as a dose increase is associated with an increase in complications, such as falls, confusion, and death. If a dose exceeds this limit, the possibility of misuse should be evaluated (Table)
Opioid-dependent patients often show typical behavior patterns, which should be viewed as signs of a medical condition rather than as a behavioral deficit.
Yes, pain patients who are dependent on opioids show “typical behavior patterns”… like squirming in their chair, hobbling instead of walking, moving slowly, and crying a lot.
Typical behavior patterns in opioid dependence
- Hoarding during periods of reduced symptoms
- Requesting new prescription although enough tablets should still be present (based on calculations)
- Receiving similar prescription drugs from other physicians or the emergency room
- Emphatically stating a desire for a dose increase
- Independently using the prescribed opioid to treat other symptoms
- Requesting a specific drug
- Reporting psychological side effects of the opioid
- Up to two unauthorized dose increases
- Selling controlled drugs
- Forging prescriptions
- Repeatedly reporting lost or destroyed prescriptions or tablets
- Repeated unauthorized dose increases
- Obtaining prescription drugs from external sources (relatives, internet, dealer)
- Stealing or “borrowing” tablets from a third party
- Using other routes of administration (such as intranasal or intravenous)
- Abuse of other substances, such as alcohol
- Tapering off an opioid
The high psychological strain on patients with chronic non-cancer pain, and their pronounced desire for treatment, can lead to the use of strong opioids, even when indications are lacking.
If the pain does NOT cause “high psychological strain”, then it’s obviously not severe. Physical pain is the correct bodily response to the threat of physical damage and is intended to induce stress to encourage avoidant action.
If pain weren’t stressful, there would be no need to treat it.
Diagnosing opioid abuse and dependence is based on the criteria of ICD-10, but it is not always possible if patients give incomplete information. Knowing risk factors and typical behavior patterns of affected patients is helpful. Further, questionnaire-based screening tools and urinalysis can help identify patients at risk.
Misuse of and dependence on opioids – Can Fam Physician. 2006 Sep – free full-text PMC article
Study of chronic pain patients
To review the evidence on identifying and managing misuse of and dependence on opioids among primary care patients with chronic pain.
QUALITY OF EVIDENCE
MEDLINE was searched using such terms as “opioid misuse” and “addiction.” The few studies on the prevalence of opioid dependence in primary care populations were based on retrospective chart reviews (level II evidence). Most recommendations regarding identification and management of opioid misuse in primary care are based on expert opinion (level III evidence).
Physicians should ask all patients receiving opioid therapy about current, past, and family history of addiction.
Physicians should take “universal precautions” that include careful prescribing and ongoing vigilance for signs of misuse.
Patients suspected of opioid misuse can be treated with a time-limited trial of structured opioid therapy if they are not acquiring opioids from other sources. The trial should consist of daily to weekly dispensing, regular urine testing, and tapering of doses of opioids. If the trial fails or is not indicated, patients should be referred for methadone or buprenorphine treatment.
Misuse of and dependence on opioids can be identified and managed successfully in primary care.
If this were true, there wouldn’t be such a problem with prescribing opioids, since misuse is supposedly easily identified and managed by even untrained (in addiction) physicians.
EDITOR’S KEY POINTS
In a recent national survey, 35% of Canadian family physicians reported that they would never prescribe opioids for moderate-to-severe chronic pain, and 37% identified addiction as a major barrier to prescribing opioids. This attitude leads to undertreatment and unnecessary suffering.
Family physicians must be able to prescribe opioids safely and effectively, and at the same time must identify and manage opioid misuse and dependence in their practices.
MEDLINE was searched using such terms as “opioid misuse” and “addiction.”
Such terms as…. exactly what?
The few studies on the prevalence of opioid dependence in primary care populations were based on retrospective chart reviews (level II evidence).
Observational studies have documented a high prevalence of opioid misuse in certain primary care patient populations, although the population prevalence is unknown. Most recommendations regarding identification and management of opioid misuse in primary care are based on expert opinion (level III evidence).
Level I evidence indicates that primary care physicians can manage opioid dependence safely and effectively with methadone or buprenorphine therapy.
Substance dependence (addiction).
Dependence occurs when patients find the psychoactive effects of a drug so reinforcing that they have difficulty controlling their use of the drug.
Addiction is characterized by the four Cs: loss of Control over use, continued use despite knowledge of harmful Consequences, Compulsion to use, and Craving. The reinforcing effects of opioids range from a mild “mood leveling” to profound euphoria.
Dependence involves 2 related phenomena, tolerance and withdrawal. Tolerance occurs when patients must take more of the drug over time to achieve the same effect.
This is a completely normal response to many kinds of drugs and substances.
Tolerance is due to compensatory changes in the number and sensitivity of central nervous system receptors.
Tolerance to the analgesic effects of opioids develops slowly; tolerance to their mood-altering effects begins within days.
This might be one of the reasons why pain patients don’t feel euphoria.
Physical symptoms of withdrawal include myalgia, and cramps and diarrhea. Psychological symptoms include anxiety, craving, and insomnia. Objective signs include lacrimation, acute rhinitis, yawning, sweating, chills, and piloerection. These signs are most evident several days after high doses of opioids are discontinued.
Withdrawal peaks 2 to 3 days after last use, and physical symptoms largely resolve by 5 to 10 days after last use, although insomnia and dysphoria can last for months afterward. Opioid withdrawal does not have medical complications except during pregnancy
Opioid misuse (or aberrant drug behaviour) refers to opioid use that is not medically sanctioned, such as dose escalation, running out of the drug early, bingeing on opioids, or crushing controlled-release tablets.
While opioid misuse can result from opioid dependence, it can also reflect inadequately treated pain, patients’ attitudes toward medication, and other factors.
Potential for abuse.
Level II evidence suggests that oxycodone has a greater risk of abuse than morphine
The abuse potential of a drug is dose-related; controlled-release preparations contain larger doses of opioids than acetaminophen-opioid preparations.
This is said to occur when patients with inadequately treated pain exhibit drug-seeking behaviour similar to that of true addicts. Consensus opinion (level III evidence) suggests that this behaviour resolves with reasonable dose increases. True addictive behaviour remains the same or worsens.
Yet such “reasonable dose increases” are virtually forbidden in our opiophobic society with all the new “guidelines”.
The reported prevalence of opioid dependence among chronic pain patients varies among clinical settings.
A review of studies conducted in tertiary care pain clinics found that prevalence ranged from 3% to 19% or more.
Other studies, generally of older patients attending specialty clinics, found rates of 1% to 3%.
In 3 retrospective chart reviews in primary care clinics, 7% to 31% of charts documented opioid misuse, and drug abuse was diagnosed in 6% of these patients.
The true prevalence of prescribed opioid misuse is unknown.
This final truth is always hidden after a long series of statistics that are intended to show high rates of problems with opioids. If such a wide range of results were found for any other variable, such damning numbers would not be so prominently displayed.
In the Health Care for Communities Study in the United States, which involved 14 000 patients, those taking prescription opioids had 4 times the risk of problems with use of prescribed and illicit drugs and of mood and anxiety disorders the other participants had.
These studies must be interpreted with caution because opioid misuse is not synonymous with opioid dependence.
Yet the ICD-10 provides only a spectrum of “dependence” that includes abuse and even addiction.
A detailed diagnostic assessment of opioid users found that non-addicted patients frequently misuse opioids.
This is because “misuse” also includes taking LESS than prescribed or not following a schedule despite fluctuating pain levels.
Risk factors for opioid dependence include
- current, past, or family history of substance abuse;
- concurrent psychiatric disorders; and
- a childhood history of sexual abuse.
Studies of the positive or negative predictive value of these risk factors have had inconsistent results.
If the results are inconsistent, why are these “inconsistently predictive” risk factors listed in this study?