Prescription Opioid Abuse in Chronic Pain: An Updated Review of Opioid Abuse Predictors and Strategies to Curb Opioid Abuse: Part 1

Abstract

Chronic pain and prescription opioid abuse are extremely prevalent both in this country and worldwide. Consequences of opioid misuse can be life-threatening with significant morbidity and mortality, exacting a heavy toll on patients, physicians, and society. Individuals with chronic pain and co-occurring substance use disorders and/or mental health disorders, are at a higher risk for misuse of prescribed opioids. Opioid abuse and misuse occurs for a variety of reasons, including self-medication, use for reward, compulsive use because of addiction, and diversion for profit. There is a significant need for treatment approaches that balance treating chronic pain; while minimizing risks for opioid abuse, misuse, and diversion. The use of chronic opioid therapy for chronic non-cancer pain has increased dramatically in the past 2 decades in conjunction with associated increases in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument which provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they arise could be of enormous benefit in clinical practice. Such an instrument could potentially curb the risk of iatrogenic addiction. Although several screening instruments and strategies have been introduced in recent years, there is no single test or instrument which can reliably and accurately predict those patients not suitable for opioid therapy or identify those who need increased vigilance or monitoring during therapy. At present, screening for opioid abuse includes assessment of premorbid and comorbid substance abuse; assessment of aberrant drug-related behaviors; risk factor stratification; and utilization of opioid assessment screening tools. Multiple opioid assessment screening tools and instruments have been developed by various authors. In addition, urine drug testing, monitoring of prescribing practices, prescription monitoring programs, opioid treatment agreements, and utilization of universal precautions are essential. Presently, a combination of strategies is recommended to stratify risk, to identify and understand aberrant drug related behaviors, and to tailor treatments accordingly. This manuscript builds on the 2012 opioid guidelines published in Pain Physician and the 2016 guidelines released by the Centers for Disease Control and Prevention. It reviews the current state of knowledge regarding the growing problem of opioid abuse and misuse; known risk factors; and methods of predicting, assessing, monitoring, and addressing opioid abuse and misuse in patients with chronic non-cancer pain.

Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain: American Society of Interventional Pain Physicians (ASIPP) Guidelines

“…Dowell et al (42) found indirect evidence for the potential utility of risk stratification and mitigation strategies for identifying risky prescribing practices, as well as behaviors. These strategies included review of PDMP data (11,12,16,(385)(386)(387)(388)(389)403,404,408,(428)(429)(430)(431)(432)(437)(438)(439)(440)(441)(442)(443)(444)(445) and UDT (440), as well as co-prescription of naloxone (441).…”

“…The role of these preventive measures and their effectiveness has been well delineated in multiple reports (408,442,443). However, one study has shown no change in the emergency department visits involving benzodiazepine misuse in early assessments from 11 metropolitan areas in the United States with PDMPs (408).…”

“…Adherence monitoring apart from clinical and behavioral assessment includes monitoring by PDMPs, UDT, and written agreements of compliance. While a national strategy for PDMPs does not exist as proposed by ASIPP in NASPER at present, PDMPs are statewide databases available in 49 states that monitor information about prescription controlled substances (48,(385)(386)(387)(388)(389)403,404,408,(439)(440)(441)(442)(443)(444)(445)(448)(449)(450)(451)(452). Even though NASPER has not been the favorite of many administrators and not mentioned in numerous reports, the state prescription monitoring programs funded by the Hal Rogers Prescription Drug Monitoring Program, named after Congressman Hal Rogers of Kentucky, has taken the lead in establishing the programs in all states, which has now become an important tool to prevent doctor shopping (451).…”

Computer‐based testing and the 12‐item Screener and Opioid Assessment for Patients with Pain‐Revised: A combined approach to improving efficiency

“…However, clinicians must be aware that patients may develop aberrant medication‐related behaviors and misuse the medication (Michna et al., ; Peirce, Smith, Abate, & Halverson, ). A comprehensive risk assessment following a standardized process, including use of prescription monitoring programs, periodic toxicology screening and assessment of risk factors with screening instruments is recommended (Atluri, Sudarshan, & Manchikanti, ; Cahana, Dansie, Theodore, Wilson, & Turk, ; Dowell, Haegerich, & Chou, ; Jamison, Serraillier, & Michna, ; Kaye et al., ).…”

Opioides y adicción en dolor crónico: ¿es un problema?, ¿cómo abordarlo?

“…del Dolor, Vol. 26, N.º 2, Marzo-Abril 2019 paciente (9) y su consentimiento para la deshabituación junto al seguimiento posterior por un equipo que incluya psicólogos/psiquiatras expertos en adicciones (10,11).…”