Opioid Therapy in Patients with Chronic Noncancer Pain: Diagnostic and Clinical Challenges

Abstract

Chronic opioid therapy for patients with chronic noncancer pain has become controversial, given the rising prevalence of opioid abuse. The prevailing literature suggests that the rate of addiction in chronic noncancer pain patients exposed to opioid therapy is relatively low, especially in those patients without significant concomitant psychiatric disorders and personal and family history of addiction. However, the escalating rate of misuse of prescription opioids has resulted in many clinicians caring for these patients to be more judicious in prescribing opioids. Accurately diagnosing addiction in chronic pain patients receiving opioids is complex. Managing the patient with pain and co-occurring opioid abuse is equally challenging. Diagnostic issues, current guidelines for the appropriate use of opioids in the chronic pain population and risk stratification models are examined. Pharmacologic and nonpharmacologic treatment strategies for the patient with pain and opioid addiction are reviewed.Chronic pain has continued to be a major healthcare problem despite noteworthy advancements in diagnostics, pharmacotherapy and invasive and noninvasive interventions. The prevalence of chronic pain is staggering, with studies indicating that more than 25% of the general population experience pain lasting more than 3 months [1, 2], with an annual economic burden of more than USD 100 billion, USD 61.2 billion of which is due to lost productivity of the workforce [3]. The economic cost of opioid misuse/abuse is also noteworthy. The prevailing literature suggests that affected individuals utilize more healthcare resources and incur higher costs [4]. It has been estimated that the cost of prescription opioid abuse in 2001 was USD 8.6 billion including workplace, criminal justice and healthcare expenditures [5].The undertreatment or mismanagement of pain can cause additional suffering to the individual afflicted with chronic pain, but can also lead to other adverse effects including delays in healing, changes in the central nervous system (neuroplasticity),

Pharmacoepidemiology of chronic noncancer pain patients requiring chronic opioid therapy: A nationwide population-based study

“…7e9 However, the safety, effectiveness and abuse potential of chronic opioid therapy (COT) in patients with chronic noncancer pain still open to debate and under controversies, given the rising prevalence of opioid abuse. 10 The prevalence of CNCP varied widely in different countries. The 1-month prevalence of moderate-to-severe CNCP, estimated using systematic review principles, was 19% in pan-Europe.…”

The Current State of Physical Therapy Pain Curricula in the United States: A Faculty Survey

“…Mismanagement of acute pain can delay healing, resulting in long-lasting changes to the peripheral and central nervous systems and consequently chronic pain. 6 Likewise, insufficient knowledge of chronic pain mechanisms and management can further create major human and economic costs for patients, families, and society. 12 In 2010, the International Pain Summit, an advocacy event of the International Association for the Study of Pain (IASP), endorsed the Declaration of Montreal, which stated that all people have the right to pain management by competently trained health care professionals.…”

Managing pain in high-risk patients within a patient-centered medical home

“…Confusion regarding terminology may account for the difficulty in accurately determining the prevalence of true "addiction" in patients receiving COT [30,31]. The influential Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) [32] outlines seven criteria defining substance dependence (addiction) including tolerance and dependence.…”