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 in the United States and worldwide. The consequences of opioid misuse can be life-threatening with significant morbidity and mortality, exacting a heavy toll on patients, physicians, and society. The risk for misuse of prescribed opioids is much higher in patients with chronic pain, especially those with concurrent substance use and /or mental health disorders. Several reasons can account for the occurrence of opioid abuse and misuse, including self-medication, use for reward, compulsive use related to addiction, and diversion for profit. There is a need, therefore, for therapeutic approaches that balance treating chronic pain, while minimizing risks for opioid abuse, misuse, and diversion. Chronic opioid therapy for chronic non-cancer pain has seen a dramatic increase throughout the past 2 decades in conjunction with associated increases in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method for selecting patients for opioid therapy, predicting risk, and identifying problems once they have arisen, could be of enormous benefit in clinical practice. An instrument as such has the potential to attenuate the risk of iatrogenic addiction. Despite the recent introduction of various screening strategies and instruments, no single test or instrument can reliably and accurately predict those patients unsuitable for opioid therapy or pinpoint those requiring heightened degrees of surveillance and monitoring throughout their therapy. Current opioid abuse screening tactics include assessing premorbid and comorbid substance abuse; assessing aberrant drug-related behaviors; stratification of risk factors; and utilizing opioid assessment screening tools. Several authors have contributed numerous screening tools and instruments to aid the assessment of appropriate opioid therapy. Additional essential measures include urine drug testing, prescription practice monitoring programs, opioid treatment agreements, and implementing universal precautions. Presently accepted recommendations consist of a combination of strategies designed to stratify risk, to identify and to understand aberrant drug-related behaviors, and to tailor treatments accordingly. This manuscript, Part 2 of a 2 part update, 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 screening, monitoring, and addressing opioid abuse and misuse in patients with chronic non-cancer pain. Key words: Opioids, misuse, abuse, chronic pain, prevalence, risk assessment, risk management, drug monitoring, aberrant drug-related behavior

Long‐term opioid therapy definitions and predictors: A systematic review

“…25,26 Reviews also examined predictors of opioid misuse and abuse, and overdose, but predictors may differ for LTOT. [27][28][29][30][31][32] Little is known about the criteria used to define LTOT for research purposes, and there has been no synthesis of the risk factors associated with transition from short-term opioid therapy to LTOT. Without an understanding of the criteria or the predictors of LTOT, it is difficult to understand the strengths and limitations regarding the evidence on the risk of LTOT, distinguish between episodic and longterm opioid use, and monitor the prevalence and incidence of LTOT.…”

“…However, in these studies, arthritis, chronic pain, tobacco use, drug disorders, and mental health disorders were consistently identified as risk factors for LTOT, many of which are similar to the risk factors associated with misuse, abuse, and overdose. [27][28][29][30][31][32] Finally, only three predictors examined prior opioid prescriptions, suggesting limited evidence on how initial prescribing may lead to LTOT. In a study not included in this review because it included pediatric patients, the number of fills and total dose during the first month of opioid use were associated with greater risk of LTOT.…”

Interprofessional care improves health-related well-being and reduces medical costs for chronic pain patients

“…In the worst case, opioid overuse leads to criminality or death. Poisoning deaths are the second most common cause of unintentional injury and death for all ages in the United States, surpassed only by motor vehicle crashes; pharmaceutical opioids are considered the primary cause of overdose death (Kaye et al, 2017b). This recent development reinforces, in our opinion, the importance of an integrated treatment plan for patients with somatoform disorder that includes much more than merely pharmacological treatment.…”

“…Patients with somatoform disorder/somatic symptom disorder are supposed to be treated nonpharmacologically first. However, in recent years the number of prescribed pain relievers (e.g., in particular opioids), has increased dramatically, especially in the United States (Kaye et al, 2017a). Misuse of such pain relievers has increased in the same proportion, leading to a higher frequency of psychiatric comorbidity, visits to emergency departments, changes in the treating doctor, and so forth (Kaye et al, 2017a(Kaye et al, , 2017b.…”

“…These factors promote a vicious cycle that intensifies patients' symptoms and disease-related behavior. Furthermore, the mean annual direct health care cost for patients who abuse opioids is 8.7 times higher than for nonabusing patients (Kaye et al, 2017a). In the worst case, opioid overuse leads to criminality or death.…”