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agate
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 Posted: Fri May 10, 2013 7:36 pm Post subject: Opioid analgesics--risky drugs, not risky patients |
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From JAMA, May 9, 2013:
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Opioid Analgesics—Risky Drugs, Not Risky Patients
Deborah Dowell, MD, MPH; Hillary V. Kunins, MD, MPH, MS; Thomas A. Farley, MD, MPH
[+] Author Affiliations: New York City Department of Health and Mental Hygiene, Queens, New York
From 1999 to 2010 the number of people in the United States dying annually from opioid analgesic–related overdoses quadrupled, from 4030 to 16,651.1 Patients' predisposition to overdose could not have changed substantially in that time; what has changed substantially is their exposure to opioids. During this same time, the amount of opioids prescribed also quadrupled.1 The increase in prescribing occurred in the context of a greater emphasis on treating pain following efforts by the American Pain Society, the Veterans Health Administration, The Joint Commission, and others to increase recognition and management of pain, as well as advocacy by pain societies urging physicians to use opioids more readily for patients with chronic noncancer pain.
Even though it is well known that prescription opioid use can lead to addiction or overdose, some opioid manufacturers and pain specialists suggest that few patients are susceptible to these risks.2- 3 To distinguish low-risk from high-risk patients, use of screening tools, including the Screener and Opioid Assessment for Patients with Pain, has been advocated.4 Medication guides include statements such as “the chance [of abuse or addiction] is higher if you are, or have been, addicted to or abused other medicines, street drugs, or alcohol, or if you have a history of mental problems.”5 While there is likely to be a gradient of risk across patients, this statement may reassure clinicians that people with opioid addiction are different from most patients for whom they provide care.
However, opioid dependence is much more common than previously believed and has been estimated to affect more than one-third of patients with chronic pain.6 No screening tool has sufficiently high sensitivity to rule out problems with opioids. Reported sensitivities of these tests for observed “aberrant drug-related behavior” (eg, dose escalation outside the treatment plan or forging prescriptions)4 among patients with chronic pain are generally within a range between 70% and 90%,4 which means that they miss 10% to 30% of patients at high risk of misuse or addiction.
In addition, some industry-sponsored educational brochures suggest that physicians should ignore signs of opioid dependence in low-risk patients.7 For instance, some patients might not be considered at high risk of misuse even though they may use more opioids than prescribed (one definition of misuse). Some authors have stated that behaviors such as taking more opioids than prescribed may represent pseudoaddiction,7 a concept introduced in a case report in 19898 as “abnormal behavior developing as a direct consequence of inadequate pain management.”8 However, this concept remains untested, without scientific studies validating diagnostic criteria or describing long-term clinical outcomes. Nonetheless, some pain societies have promoted this concept9 and suggest that some patients demonstrating behaviors typical of opioid addiction may actually require higher doses.9
Rather than representing iatrogenic undertreatment of pain, however, behaviors described as pseudoaddiction may represent predictable responses to opioid exposure. Long-term opioid use typically results in tolerance. A standard clinical solution is to increase opioid dose. However, contrary to the view that there is no maximum safe dose if opioids are increased gradually over time, death from opioid overdose becomes more likely at higher doses.
The most important risk factor for opioid analgesic–associated dependence or overdose is not a feature of any individual patient but instead simply involves receiving a prescription for opioids. For example, newly prescribed opioids after short-stay surgery are associated with a 44% increase in risk of becoming a long-term opioid user within 1 year.10
Another potential complication of screening for risk of opioid abuse is that identifying patients who should not receive opioids can stigmatize them, leading to consequences that do not help them. Patients who are questioned about substance use and then excluded from an expected treatment may feel embarrassed or abandoned. The decision to address a patient's pain should not depend on substance use history. Screening should be used primarily to identify and offer treatment to patients with opioid addiction.
Before prescribing opioids, a more useful and important question than a patient's likelihood of dependence is whether benefits of opioids in relieving pain are likely to outweigh the risks of the drugs. For pain control at the end of life, the answer to this question is often yes. If the indication for opioids is chronic noncancer pain, the answer to this question will be no much more often than many physicians may realize. Despite widely held views about the efficacy of opioids for pain control, systematic reviews have not found sufficient evidence that long-term opioid use controls noncancer pain more effectively than other treatments.
Physicians have a professional and ethical responsibility to understand the expected benefits and risks of medications and to balance these appropriately. When benefits of opioids are likely to outweigh risks, such as in severe acute pain unlikely to respond to other therapies, it is appropriate to use opioids, prescribing the lowest effective dose and with a duration limited to the likely duration of the acute pain. However, when risks outweigh benefits, as will often be the case for chronic pain, opioid use should be avoided in favor of other treatments.
Some physicians may think that only a small fraction of their patients are put at risk by taking high doses of opioids. However, the risk of opioids stems primarily from these drugs, not from patients. Low-risk patients given large enough doses will have a high risk of overdose. Patients given moderate doses for prolonged periods will have a high risk of opioid dependence. While a patient's estimated individual risk should be considered, physicians should pay close attention to the drug dose and duration. All patients exposed to opioids would benefit from judicious prescribing and close follow-up.
AUTHOR INFORMATION
Corresponding Author:
Deborah Dowell, MD, MPH, New York City Department of Health and Mental Hygiene, 42-09 28th St, Eighth Floor, Queens, NY 11101 (ddowell1@health.nyc.gov).
Conflict of Interest Disclosures:
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. |
The article can be seen here.
I recently read a book about Oxycontin, which indicated that the problem of too-easy access to this addictive drug is reaching frightening proportions. The book is Pain Killer: A "Wonder" Drug's Trail of Addiction and Death (2003) by Barry Meier. |
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agate
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Location: Oregon
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| Posted: Tue May 14, 2013 6:10 pm Post subject: JAMA on misuse of opioid medication |
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From JAMA, May 15, 2013:
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JAMA Patient Page
Misuse of Opioid Medication
Daniel P. Alford, MD, MPH; Edward H. Livingston, MD
JAMA. 2013;309(19):2055.
About 100 million Americans have chronic pain and some may be treated with opioid medications. Opioid medications include codeine, morphine, oxycodone, and fentanyl, among others. These medications can help some people and harm others. In the United States, opioid medications are the second most common drug abused after marijuana. Opioid medication misuse is defined as use of an opioid medication different than the way in which it was prescribed (for example, in higher doses) or for reasons other than why it was prescribed (for example, to get high). An article published in the March 6, 2013, issue of JAMA discussed opioid misuse.
RISK FACTORS FOR OPIOID MEDICATION MISUSE
Younger age (<45 years)
Personal history of substance abuse, mental illness, or legal problems
Family history of substance abuse
WHAT YOU SHOULD KNOW ABOUT USING OPIOIDS
Not all chronic pain gets better with use of opioids. Opioids can cause side effects, addiction, overdose, and death. Before prescribing opioids, your doctor will need to teach you about how opioid medications can help you and how they can harm you. This may include having you sign an agreement form.
Using opioids safely includes:
~Not chewing or crushing the medication
~Not increasing the dose on your own
~Not sharing the medication with others
~Keeping the medication safe from others
~Throwing out extra opioid medications by mixing them with used coffee grounds or cat litter
The risk of harm from opioids is highest:
~When the opioid medication is started
~When the dose is increased
~With a high dose (for example, more than 100 mg of morphine)
~When also taking sleep or anxiety medications or using alcohol
MONITORING FOR BENEFIT AND HARM
When you first begin taking an opioid medication, your doctor should see you often. To know if the opioids are helping you, your doctor will ask you if your pain and function are getting better. Your doctor will also look for evidence that the opioids are not helping, are being misused, or are harming you by causing side effects that are unsafe or that stop you from performing your normal daily activities. To check for opioid medication misuse, your doctor may use urine drug tests, pill counts, and official websites that show your prescription history. Urine drug tests are helpful to make sure the opioid is being taken and to see if there is any other drug abuse. Pill counts are helpful to see if you are taking the medication as prescribed.
Official websites are helpful to show whether other doctors are prescribing medications to you. If your doctor is worried about opioid medication misuse (for example, if no opioid is found in the urine or an incorrect number of pills remain in your pill bottle), your doctor may decide that the opioid medication is too dangerous for you and will need to be stopped. If your body is physically dependent on the opioid, your doctor may decrease the opioid dose slowly so that you do not get sick from withdrawal.
FOR MORE INFORMATION
US Food and Drug Administration
http://www.fda.gov
Substance Abuse and Mental Health Services Administration
http://www.samhsa.gov
US Drug Enforcement Administration
www.deadiversion.usdoj.gov
INFORM YOURSELF
Sources:
US Food and Drug Administration, Substance Abuse and Mental Health Services Administration, US Drug Enforcement Administration
Conflict of Interest Disclosures:
The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. |
The article can be seen here. |
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