Managing Two Edges of the Opioid Sword

Americans are in excruciating pain. Pain is the second most common reason people seek medical care. The Associated Press recently reported that pharmacies sold enough oxycodone and hydrocodone in 2010 to give 40 Percocet (5-mg) tablets and 24 Vicodin (5-mg) tablets to every man, woman and child in the United States.

Opioids are the quintessential blessing and curse. Nothing is more potent for pain relief when taken responsibly, nor more disruptive to the patient-clinician relationship when abused. Litigation risks are a threat for both overtreatment that leads to overdose and addiction, and undertreatment of pain. Dose escalations in patients with nonmalignant chronic pain raise tensions and suspicions. And the clinician trying to root out addicted patients seeking a “legal high” can cause unnecessary suffering in nonaddicted patients who are legitimately seeking pain relief.

Medication nonadherence is a common red flag of potential addiction among long-term opioid users. But that doesn’t mean we should “cut off” every patient who is nonadherent because we suspect addiction.

Dr. Robert M. Jamison of Brigham & Women’s Hospital in Boston and colleagues published an investigation evaluating whether close monitoring and substance abuse counseling could increase opioid compliance among patients demonstrating risk for opioid misuse (Pain 2010;150:390-400).

They conducted a randomized trial enrolling patients with back pain (N = 62) who were prescribed opioid therapy for longer than 6 months and who had a risk for, or history of, prescription opioid misuse (defined as “the use of any drug in a manner other than how it is indicated or prescribed”). The intervention consisted of group sessions in which risk factors regarding opioid use were discussed, compliance was reviewed, substance misuse and opioid compliance worksheets were completed, and urine screens were conducted.

Group and individual sessions focused on abstaining from illicit drug use, coping with urges to misuse medications, problem-solving related to substance misuse, and lifestyle balance. The intervention reduced scores on a standardized measure of drug misuse and support the utility of such an approach among chronic pain patients at high risk for prescription opioid misuse.

Of course, this type of intervention is not practical for the primary care physician. But this study highlights two important clinical considerations. First, patients with a history of drug abuse or who are otherwise “at risk” for current drug misuse also experience pain commonly necessitating the use of opioids. This may be confusing and anxiety-provoking for many. This leads us to the second consideration which is that we need to reach out and ask for assistance from pain specialists when we are wading into uncharted or uncertain waters. Soliciting help from our specialty colleagues when we need it helps reduce pain all around.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. The opinions expressed are solely those of the author. E-mail him at [email protected].

Americans are in excruciating pain. Pain is the second most common reason people seek medical care. The Associated Press recently reported that pharmacies sold enough oxycodone and hydrocodone in 2010 to give 40 Percocet (5-mg) tablets and 24 Vicodin (5-mg) tablets to every man, woman and child in the United States.

Opioids are the quintessential blessing and curse. Nothing is more potent for pain relief when taken responsibly, nor more disruptive to the patient-clinician relationship when abused. Litigation risks are a threat for both overtreatment that leads to overdose and addiction, and undertreatment of pain. Dose escalations in patients with nonmalignant chronic pain raise tensions and suspicions. And the clinician trying to root out addicted patients seeking a “legal high” can cause unnecessary suffering in nonaddicted patients who are legitimately seeking pain relief.

Medication nonadherence is a common red flag of potential addiction among long-term opioid users. But that doesn’t mean we should “cut off” every patient who is nonadherent because we suspect addiction.

Dr. Robert M. Jamison of Brigham & Women’s Hospital in Boston and colleagues published an investigation evaluating whether close monitoring and substance abuse counseling could increase opioid compliance among patients demonstrating risk for opioid misuse (Pain 2010;150:390-400).

They conducted a randomized trial enrolling patients with back pain (N = 62) who were prescribed opioid therapy for longer than 6 months and who had a risk for, or history of, prescription opioid misuse (defined as “the use of any drug in a manner other than how it is indicated or prescribed”). The intervention consisted of group sessions in which risk factors regarding opioid use were discussed, compliance was reviewed, substance misuse and opioid compliance worksheets were completed, and urine screens were conducted.

Group and individual sessions focused on abstaining from illicit drug use, coping with urges to misuse medications, problem-solving related to substance misuse, and lifestyle balance. The intervention reduced scores on a standardized measure of drug misuse and support the utility of such an approach among chronic pain patients at high risk for prescription opioid misuse.

Of course, this type of intervention is not practical for the primary care physician. But this study highlights two important clinical considerations. First, patients with a history of drug abuse or who are otherwise “at risk” for current drug misuse also experience pain commonly necessitating the use of opioids. This may be confusing and anxiety-provoking for many. This leads us to the second consideration which is that we need to reach out and ask for assistance from pain specialists when we are wading into uncharted or uncertain waters. Soliciting help from our specialty colleagues when we need it helps reduce pain all around.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. The opinions expressed are solely those of the author. E-mail him at [email protected].

Americans are in excruciating pain. Pain is the second most common reason people seek medical care. The Associated Press recently reported that pharmacies sold enough oxycodone and hydrocodone in 2010 to give 40 Percocet (5-mg) tablets and 24 Vicodin (5-mg) tablets to every man, woman and child in the United States.

Opioids are the quintessential blessing and curse. Nothing is more potent for pain relief when taken responsibly, nor more disruptive to the patient-clinician relationship when abused. Litigation risks are a threat for both overtreatment that leads to overdose and addiction, and undertreatment of pain. Dose escalations in patients with nonmalignant chronic pain raise tensions and suspicions. And the clinician trying to root out addicted patients seeking a “legal high” can cause unnecessary suffering in nonaddicted patients who are legitimately seeking pain relief.

Medication nonadherence is a common red flag of potential addiction among long-term opioid users. But that doesn’t mean we should “cut off” every patient who is nonadherent because we suspect addiction.

Dr. Robert M. Jamison of Brigham & Women’s Hospital in Boston and colleagues published an investigation evaluating whether close monitoring and substance abuse counseling could increase opioid compliance among patients demonstrating risk for opioid misuse (Pain 2010;150:390-400).

They conducted a randomized trial enrolling patients with back pain (N = 62) who were prescribed opioid therapy for longer than 6 months and who had a risk for, or history of, prescription opioid misuse (defined as “the use of any drug in a manner other than how it is indicated or prescribed”). The intervention consisted of group sessions in which risk factors regarding opioid use were discussed, compliance was reviewed, substance misuse and opioid compliance worksheets were completed, and urine screens were conducted.

Group and individual sessions focused on abstaining from illicit drug use, coping with urges to misuse medications, problem-solving related to substance misuse, and lifestyle balance. The intervention reduced scores on a standardized measure of drug misuse and support the utility of such an approach among chronic pain patients at high risk for prescription opioid misuse.

Of course, this type of intervention is not practical for the primary care physician. But this study highlights two important clinical considerations. First, patients with a history of drug abuse or who are otherwise “at risk” for current drug misuse also experience pain commonly necessitating the use of opioids. This may be confusing and anxiety-provoking for many. This leads us to the second consideration which is that we need to reach out and ask for assistance from pain specialists when we are wading into uncharted or uncertain waters. Soliciting help from our specialty colleagues when we need it helps reduce pain all around.

Jon O. Ebbert, M.D., is a professor of medicine and a primary care clinician at the Mayo Clinic in Rochester, Minn. The opinions expressed are solely those of the author. E-mail him at [email protected].