Management of opioid medications in patients with chronic pain and risk of substance misuse

Abstract

When prescribed appropriately and used as prescribed, opioid medications can safely and effectively treat pain. Best practices with respect to their use in chronic non-cancer-related pain (CNCP) are evolving. Opioids may be subject to misuse for a variety of purposes, including self-medication, use for reward, compulsive use because of addiction, and diversion for profit. Individuals with chronic pain and co-occurring substance use, mental health disorders, and other conditions may be at increased risk for misuse of prescribed opioids. Interdisciplinary pain management, the use of universal precautions in all patients, and special attention to the structure of care in those at higher risk for opioid misuse may improve outcomes in opioid treatment of CNCP. This article discusses evolving research and clinical literature related to the care of individuals with CNCP at a higher risk for opioid misuse.

Adherence to Clinical Guidelines for Opioid Therapy for Chronic Pain in Patients with Substance Use Disorder

“…40 In contrast to previous findings, patients with SUD were not prescribed higher opioid doses 17 , despite statistically significant differences in pain scores. Patients with SUD may have decreased pain thresholds, suggesting the need for higher doses to achieve a similar response.…”

Dynamic risk factors in the misuse of opioid analgesics

“…Some patients who display aberrant drug-related behaviors and misuse opioids are trying to manage uncontrolled pain [31]. While inadequate analgesia may contribute to aberrant drug-related behaviors, in some cases, effective analgesia also contributed led to aberrant drug behaviors [32].…”

Tolerance to the antinociceptive and hypothermic effects of morphine is mediated by multiple isoforms of c-Jun N-terminal kinase

“…As a result, it is a crucial receptor in the modulation of pain circuitry at both the supra-spinal and spinal level. Activation of MOR also causes euphoria, which plays a role in the high addictive liability of opiates [4, 5]. Opioid dependence is compounded by the development of tolerance, which can cause an escalation of dose and a progression to dependence [6].…”

“…There are multiple mechanisms that may act to mediate opioid tolerance [5, 6]. One process termed desensitization occurs with the loss of MOR-effector coupling following opioid administration, and appears to be mediated through phosphorylation of the receptor and subsequent recruitment of β-arrestin [7].…”