Opioids in Chronic Pain Management – Navigating Between Effect and Addiction

By Henriette Poulsen, M.D and Kim Kristiansen, M.D.

The American Centers for Disease Control and Prevention (CDC) have recently published numbers indicating a huge increase of non-medical use of opioid pain relievers¹. Nonmedical use is defined as use of a prescription pain reliever without a prescription belonging to the respondent or use for the experience or feeling the drugs causes. It is equally terrifying that also the numbers of deaths caused by overdoses of these drugs – initially supposed to be prescribed by doctors to ease the suffering of those in pain – have increased.  Now surpassing the number of deaths caused by heroin and cocaine combined.

Previously this year in a report published by the Institute of Medicine (IOM)² it is estimated that chronic pain is affecting a staggering 116 million American adults.

In our hospital and practice rotations we as doctors notice this much: Pain is a very common symptom and all the drugs used to treat it have serious side effects and a potential to poison, which should be considered when prescribing them.

In surgery we have met patients vomiting blood due to NSAIDs and patients with bowel obstruction mainly due to the use of opioids. In internal medicine we try to prevent the liver failure of young girls who have ingested too much paracetamol/acetaminophen and have treated heart failure by stopping patients using NSAIDs. In the middle of the night comatose patients arrive in the ER – and the first thing to do is to check the pupils – could this patient have an opioid overdose?

In psychiatry – we meet the addicts. The addiction to drugs (prescription and/or illegal) and alcohol plays a big role when trying to diagnose and treat patients with psychiatric illnesses.  Getting the patients “off” the drugs often constitutes the first part of the treatment. And we meet people suffering a NEED for a drug so badly that they have broken every deal made, cried, pleaded, begged and stolen for yet another high and  lost their jobs, spouse, children and every hope of a future. So much mental anguish.

The dilemma is obvious: When we prescribe opioids to treat pain: How do we prevent creating an addict and is it even possible? And evenly important: how do we prevent indirectly supplying an existing addict as evidence shows that many take opioids not prescribed to them? At the same time we don’t wish to limit the possibilities of our chronic pain patients to get an increased quality of life.

This dilemma has been discussed in many scientific journals, pain blogs and newspaper articles.

A Medline/Pubmed search reveals several national and international guidelines on prescribing opiods, different questionnaires designed to determine the risk of opioid addiction, pro and cons of making opioid treatment contracts with patients and how to monitor for signs of diversion including the use of urine testing.

Most agree that opioids DO have a place in treating chronic pain. And no one disagrees that opioids have an addictive potential. But for some, avoiding that patients become addicted is the PRIMARY goal whereas others primarily fear the risks of UNDER TREATMENT and STIGMATISM when the patient’s use of opioids is strictly controlled and restricted.

This is beautifully illustrated by the comments to an article published in the Canadian Family Physician earlier this year about the increased risk of opioid related deaths among patients treated by physicians who prescribe opioids frequently³.

We believe that one thing doesn’t necessarily exclude the other.

Chronic pain is a complex condition, which requires a multidimensional approach. Research has taught us, that chronic pain is not just acute pain lasting a longer time, and therefore it shall not be treated as such. Indeed the treatment of patients with chronic pain requires a multidimensional approach which must be treated from a more holistic point of view involving pharmacological as well as non-pharmacological treatment modalities. The use of opiods are only one small piece of the puzzle and it is crucial to keep focus on improving the Quality of Life. Considering also that opioids don’t have the same effect on all types of pain the expected benefits and risks should be assessed and discussed with the patient before use. The patient should be informed about the risk of addiction. Much as the benefits of treating a patient with NSAIDS should be measured against the risk of heart failure and gastrointestinal bleeding – by considering existing risk factors. In our experience most patients DO have concerns about addiction – and also as being seen as an addict because they need opioids to treat their pain, no matter if they have developed addictive symptoms or not. The patient should be informed about what it means to be addicted, the current knowledge about the mechanisms and how to recognize the early signs. And most importantly: the use  should be MONITORED – and follow-up visits scheduled. Here the effects or lack thereof should be assessed and enquiries about adherence and side-effects – INCLUDING signs of addiction – should be made.

But to do this the right way we need to know this: What IS opioid addiction and why do some people develop this terrible reaction to the opioids prescribed?

During the next weeks we will discuss this in the blog posts – and also how we  as patients  as well as healthcare professionals can navigate as safely as possible in this.

1. CDC:  Vital Signs: Overdoses of Prescription Opioid Pain Relievers — United States, 1999—2008. November 2011 Morbidity and Mortality Weekly Report (MMWR) http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6043a4.htm?s_cid=mm6043a4_w
2. IOM: Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education and Research. June 2011. http://www.iom.edu/Reports/2011/Relieving-Pain-in-America-A-Blueprint-for-Transforming-Prevention-Care-Education-Research.aspx
3. Dhalla IA et al: Clustering of opioid prescribing and opioid-related mortality among family physicians in Ontario. Canadian Family Physician. 57(3). 2011: e92-6 http://www.cfp.ca/content/57/3/e92.long#responses

Henriette Poulsen, M.D and Kim Kristiansen, M.D. (2011). Opioids in Chronic Pain Management – Navigating Between Effect and Addiction Picture of Pain Blog : http://blog.dolotest.com/2011/12/01/opioids-in-chronic-pain-management-navigating-between-effect-and-addiction/