Monday, May 10, 2010

Pain Patients Opioid Misuse

One of the difficulties facing many physicians now is the concern about how to treat chronic pain patients. The risk of course is that the opioids (hydocodone, oxycodone, Oxycontin, morphine) used to treat chronic pain may result in misuse, diversion of, and addiction to these medications. We know these medications are very often misused and the abuse of these medications is rising faster than any other drug use. So why are they being so frequently prescribed?

There has been a great interest among accrediting organizations, specialty groups, and the public in providing adequate relief of chronic pain. Hospitals can lose their accreditation if pain is not adequately treated. Physicians are at risk for malpractice and in one case a physician was prosecuted for not providing "adequate" methods of pain management. The problem is that except for the risk of addiction or overdose the opioids are medically safer than the alternatives. Chronic use of the non steroidal anti-inflammatory drugs (NSAIDS) can lead to potentially severe consequences such as renal damage, liver problems, and gastrointestinal bleeding. Recommending these medications instead of providing opioids for chronic pain patients can at times be considered malpractice.

So what is a physician to do? Many (wisely I believe)refer all their pain patients to a pain specialist. A number of physicians don't have that option so they are left with not treating the patient at all for any medical condition or providing medications that are at high risk of being misused. Any information that can assist with this quandary is very helpful.

First, the American Society of Addiction Medicine (ASAM) has published guidelines for reducing risk of abuse but most physicians are unaware of them. A recent study in the April issue of the Journal of Pain gives us an additional piece of information. A study of 662 patients with non chronic pain were evaluated. 37% of women and 31% of the men in the study were found to be misusing or abusing their medication. There was a difference though in who was misusing the opioids. The women tended to use the opioids to manage mood states including depression and anxiety. Women who had an anxiety or depression diagnosis were much more likely to abuse the medication. Men however misused the opioids to get high, and this was much more likely if the person had close friends who abused alcohol or drugs, had legal problems, bad temper, and personal histories of past or concurrent drug or alcohol.

So, while we can't predict the outcome regarding who will abuse their opioids when treated for chronic pain we do have some idea of the high risk groups that probably warrant more than usual monitoring.

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