Chronic Pain Management with Opioids in Patients with Past or Current Substance Abuse Problems (original) (raw)
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Pain physician, 2006
Opioids are used extensively for chronic pain management in the United States. The frequency of opioid use prior to presenting to interventional pain management settings and in interventional pain management settings has been shown to be above 90%. Opioid abuse has been demonstrated in 9% to 41% of patients receiving chronic pain management. Illicit drug use has been reported in 14% to 34% of patients in chronic pain management settings. To evaluate and correlate multiple variables with opioid abuse and illicit drug use. A prospective, consecutive study. Interventional pain management practice setting in the United States. A total of 500 consecutive patients prescribed opioids, considered to be receiving stable doses of opioids supplemental to their interventional techniques were evaluated for opioid abuse and for illicit drug use. Abuse was defined as a patient receiving controlled substances from any source other than the prescribing physician at our center with the exception of c...
Assessment and Treatment of Abuse Risk in Opioid Prescribing for Chronic Pain
Pain Research and Treatment, 2011
Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drugrelated behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no "gold standard" for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.
Pain physician, 2004
Over the years, there has been a shift toward the increased reliance on opioids for the treatment of chronic pain. It is well known that some patients do not provide an appropriate history or underestimate their drug intake, and may exaggerate reported pain levels. Numerous studies have documented the incidence of illicit drug use and abuse of opioids in chronic pain patients. It is not known what proportion of patients have already been exposed to controlled substances prior to presenting for interventional pain management. To evaluate and identify the prevalence of controlled substance use, demographic characteristics, and psychological characteristics of patients presenting for interventional pain management along with illicit drug use. A prospective, observational study. A total of 100 patients presenting at an interventional pain management setting for initial evaluation were evaluated by detailed history and urine drug testing for controlled substance use and illicit drug use....
Opioid analgesic-treated chronic pain patients at risk for problematic use
The American journal of managed care, 2013
To characterize potentially problematic opioid use (PPOU) among opioid analgesic-treated chronic pain (OAT-CP) patients and to compare their healthcare service utilization and expenditures with those of a control group of OAT-CP patients not exhibiting these behaviors. Cross-sectional, retrospective analysis of health claims data. Members of a national health plan (n = 3891) with chronic pain and an opioid prescription were categorized into 3 groups: PPOU group (n = 1499), those displaying evidence of doctor shopping or rapid opioid dose escalation; buprenorphine/naloxone group (n =199), those who filled a prescription for buprenorphine/naloxone, which served as a proxy for opioid dependence; and control group (n = 2193), those not meeting either of the above criteria. Groups were compared on 1-year healthcare service utilization and costs. The PPOU group made up more than one-third of the study sample. Compared with the control group, they incurred significantly greater 1-year adju...
Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial
Pain, 2010
Chronic pain patients who show aberrant drug-related behavior often are discontinued from treatment when they are noncompliant with their use of opioids for pain. The purpose of this study was to conduct a randomized trial in patients who were prescribed opioids for noncancer back pain and who showed risk potential for or demonstration of opioid misuse to see if close monitoring and cognitive behavioral substance misuse counseling could increase overall compliance with opioids. Forty-two patients meeting criteria for high-risk for opioid misuse were randomized to either standard control (High-Risk Control; N=21) or experimental compliance treatment consisting of monthly urine screens, compliance checklists, and individual and group motivational counseling (High-Risk Experimental; N=21). Twenty patients who met criteria indicating low potential for misuse were recruited to a low-risk control group (Low-Risk Control). Patients were followed for 6 months and completed pre- and post-stu...
Drug and Alcohol Dependence, 2018
Aims To compare specific substance misuse in treatment-seeking, opioiddependent patients with and without comorbid chronic pain, and to assess the respective value of urinalysis and patient reports in assessing substance misuse. Methods Participants comprised a clinical population in a regional NHS Substance Misuse Service in the East of Scotland (N=521). The Brief Pain Inventory-Short Form was used to assess pain and the Maudsley Addiction Profile and urinalysis were used to assess substance misuse at study inception. Urinalysis was used to assess substance misuse during the 5-year followup period. Data were hosted, linked, anonymised and analysed within a national Safe Haven. Results Compared with opioid-dependent patients with no pain, a significantly higher proportion of treatment-seeking, opioid-dependent patients with chronic pain were engaged in non-medical benzodiazepine use (69% versus 58%; p=0.016) and illicit cannabinoid use (84% versus 65%; p=0.025) at study inception. Furthermore, a significantly higher proportion of this group was shown to continue non-medical benzodiazepine use (70% versus 42%; p=0.037) and illicit cannabinoid use (100% versus 32%; p=0.002) during the 5-year follow-up period. There were significant correlations between drug screen results and patient-reported use of opioids (Tetrachoric ϱ=0.4944; p<0.001), benzodiazepines (Tetrachoric ϱ=0.2641; p=0.001) and cannabinoids (Tetrachoric ϱ=0.8384; p<0.001). Conclusions Whilst gaining control of illicit opioid use during treatment, opioiddependent patients with comorbid chronic pain demonstrated persistent problematic use of benzodiazepines and cannabinoids. This pattern of misuse was shown to persist during the 5-year follow-up period.
Pain Medicine, 2009
Objective. To identify demographic and clinical predictors of the resolution of aberrant drug-related behaviors (ADRBs) in a group of patients referred to the Opioid Renewal Clinic (ORC) by their primary care providers (PCPs). ORC is a program supporting PCPs' use of opioids for chronic pain in patients perceived as at risk for opioid abuse or those with demonstrated ADRBs. Methods. A retrospective chart review was conducted for 195 consecutive subjects referred to the ORC from January 17, 2002 to August 27, 2004, for ADRBs. Binary logistic regression was employed to identify independent predictors of aberrant behavior outcome at 1 year. Results. Of the 195 referred, 45.6% (N = 89) resolved their ADRB at 1 year. Other outcomes, classified as nonresolution of ADRB, self-discharged or discharged by the ORC for inability to adhere to the opioid treatment agreement (N = 86, 44.1%) and acceptance of referral for addiction treatment (N = 20, 10.2%). A history of cocaine abuse increased the odds of failing the program by five times (odds ratio [OR] = 4.97, P = 0.001). Each additional pain diagnosis reduced the odds of failure by 16% (OR = 0.837, P = 0.008). When compared with singles, married individuals were 62% less likely to fail the ORC program (OR = 0.38, P = 0.028). Conclusions. Nearly half of the patients resolved their aberrant behavior within the ORC. Patients with cocaine abuse were at higher risk for failure, suggesting a need for further research into safe and effective ways to manage pain in this complex subset of patients. Aberrant behaviors tended to resolve in patients with multiple pain locations, possibly because of their desire for relief.
Pain Management of Patients with Substance Abuse in the Ambulatory Setting
Current pain and headache reports, 2017
Abuse of illicit substances and prescription opioids is a growing problem that presents challenges for pain management in the inpatient and outpatient setting. With future patient care models shifting toward shorter hospital stays and more same-day surgeries, it is crucial that clinicians learn to manage this patient population and strike a balance between the overtreatment of pain that can subsequently worsen tolerance and addiction, and the undertreatment of pain that can lead to pseudoaddiction. Through recognition of maladaptive behaviors, use of screening programs, and pain contracts, physicians in the outpatient setting can improve their oversight and shepherding of these patients. In the inpatient setting, regularly scheduled rather than PRN opioids are recommended for chronic opioid users, and good communication with the patient's outpatient prescriber of pain medications is essential. For surgical patients on chronic opioid therapy, making a multimodal plan in advance o...
Predictors of opioid misuse in patients with chronic pain: a prospective cohort study
2006
Background: Opioid misuse can complicate chronic pain management, and the non-medical use of opioids is a growing public health problem. The incidence and risk factors for opioid misuse in patients with chronic pain, however, have not been well characterized. We conducted a prospective cohort study to determine the one-year incidence and predictors of opioid misuse among patients enrolled in a chronic pain disease management program within an academic internal medicine practice. Methods: One-hundred and ninety-six opioid-treated patients with chronic, non-cancer pain of at least three months duration were monitored for opioid misuse at pre-defined intervals. Opioid misuse was defined as: 1. Negative urine toxicological screen (UTS) for prescribed opioids; 2. UTS positive for opioids or controlled substances not prescribed by our practice; 3. Evidence of procurement of opioids from multiple providers; 4. Diversion of opioids; 5. Prescription forgery; or 6. Stimulants (cocaine or amphetamines) on UTS. Results: The mean patient age was 52 years, 55% were male, and 75% were white. Sixty-two of 196 (32%) patients committed opioid misuse. Detection of cocaine or amphetamines on UTS was the most common form of misuse (40.3% of misusers). In bivariate analysis, misusers were more likely than non-misusers to be younger (48 years vs 54 years, p < 0.001), male (59.6% vs. 38%; p = 0.023), have past alcohol abuse (44% vs 23%; p = 0.004), past cocaine abuse (68% vs 21%; p < 0.001), or have a previous drug or DUI conviction (40% vs 11%; p < 0.001%). In multivariate analyses, age, past cocaine abuse (OR, 4.3), drug or DUI conviction (OR, 2.6), and a past alcohol abuse (OR, 2.6) persisted as predictors of misuse. Race, income, education, depression score, disability score, pain score, and literacy were not associated with misuse. No relationship between pain scores and misuse emerged.
July 2012, 2012
Both chronic pain and prescription opioid abuse are prevalent and continue to exact 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. Treatment approaches that balance treating chronic pain while minimizing risks for opioid abuse, misuse, and diversion are much needed. The use of chronic opioid therapy for chronic noncancer pain has increased dramatically in the past 2 decades in conjunction with a marked increase in the abuse of prescribed opioids and accidental opioid overdoses. Consequently, a validated screening instrument that provides an effective and rational method of selecting patients for opioid therapy, predicting risk, and identifying problems once they a...