Special Topics in Pain: Opioids

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

Author(s): Kaye AD, et al.
Journal: Pain Physician. 2017; 20:S93-S109. 207 references.
Reprint: Alan D. Kaye, MD, PhD, Department of Anesthesiology, LSU Health, 1542 Tulane Ave. Rm # 656, New Orleans, LA 70112. E-mail: alankaye44@hotmail.com
Faculty Disclosure: Abstracted by N Walea, who has nothing to disclose.
Objective: Review and evaluate the latest advances and newest information in the area of Opioids

Editor’s Note: This is a useful article on factors which increase risk for opioid abuse.

Class: Pharmacology: opioids (abuse)

Although nonpharmacologic therapy is preferred, the use of chronic opioid therapy (COT) for chronic non-cancer pain (CNCP) has increased dramatically in the past two decades. Significantly more men than women had lifetime (15.9% vs 11.2%) and past-year (5.9% vs 4.2%) use in the 2007 National Survey on Drug Use and Health (NSDUH). Men are more likely than women to obtain prescription opioids for free from family or friends, and are more likely to purchase them from a dealer. Polysubstance use and treatment underutilization are common among both sexes but fewer women than men receive alcohol or drug abuse treatment. Studies have reported a significant association of young, white men with prescription use.

Women are at greater risk of misusing opioids because of emotion issues and affective distress, whereas men tend to misuse opioids because of legal and problematic behavioral issues. Nonmedical use of prescription opioids among men but not women was associated with past-year inhalant us in one survey. In women, who first used illicit drugs at 24 years or older, serious mental illness, and cigarette smoking were associated with the nonmedical use of opioids.

Although substance abuse is rarely associated with individuals nearing or at retirement age, there is an increasing need to understand the nature and extent of drug use among older adult populations. Findings suggest elderly patients often misuse their own prescriptions for pain management. Patients classified at high risk for opioid misuse report more subjective pain, multiple pain complaints, and a greater degree of pain-related limitation. Low pain tolerance in patients with active and past addictions has been reported.

Prior studies indicate individuals who are younger; unmarried; unemployed; have a lower education level; have poor/fair health; and use tobacco, alcohol, and illicit drugs are more likely to engage in nonmedical use of prescription drugs (NMUPD) and abuse or depend on prescription drugs (ADPD). Multiple studies have indicated that health insurance has been found to be negatively associated with NMUPD. Similarly, individuals with lower family incomes (< $20,000) are more likely to have lower education and consequently poor knowledge about the harms of NMUPD.

The association between nonmedical use of prescription drugs or abuse/dependence and mental disorders has been well documented in the literature. A history of mood disorder, psychological problems, and psychosocial stressors increases the risk for prescription opioid misuse. Panic, social phobia and agoraphobia, low self-rated health status, and other substance misuse should alert clinicians to screen for abuse and dependence. Depression and anxiety disorders partially account for higher rates of abuse reported in patients taking opioid analgesics compared with those not taking prescribed opioids. Substance abuse among those with schizophrenia is common and is associated with poor clinical outcomes.

The most consistent variable that has been associated with prescription opioid misuse is a history of substance use disorders (SUD). Patients with chronic pain have high rates of comorbid SUDs. A detailed substance abuse history and in-depth evaluation are needed to identify the patient with pain who is at risk for abuse and/or diversion of prescribed opioids. The µ-opioid receptor is the primary target of opioids and targeted deletions of µ-opioid receptor gene (OPRM!) in mice established its role in the rewarding effects of morphine. Many functional variations were identified in the OPRM1; the most common variants associated with greater risk for opioid addiction are the 118A>G and the 17C>T SNP in the coding region of the OPRM1. In addition to variants in the opioid receptor genes, a variety of other related and unrelated genes that contribute to opioid dependency have been identified.

Important Points:
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. Presently, a combination of strategies is recommended to stratify risk, to identify and understand aberrant drug related behaviors, and to tailor treatment accordingly.

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