Myths and Misconceptions Surrounding Addiction in Chronic Pain Patients Treated with Opioid Analgesics

Just how prevalent is addiction among chronic pain patients treated with prescription opioid medications? Reports have varied over the years, with rates dependent on the criteria and definitions used to describe “addiction,” the patient population studied, and other factors. However, with proper risk management, patient selection, attention to prescribing guidelines, and follow-up testing and monitoring for signs of aberrant behaviors, the rate of addiction appears to be much lower than is assumed by many clinicians and patients.

For example, a study involving more than 1,100 patients published by Passik, et al. in the Journal of Pain and Symptom Management (http://hcp.lv/rb98RZ) found that “the incidence of drug abuse events and aberrant drugrelated behaviors was relatively low” among this population, “probably because of the implementation of universal precautions” and other factors (although the authors also pointed out that the fact that events did occur, despite the controlled study setting, highlighted “the limits of screening and the need for ongoing monitoring of aberrant behavior”). Another review article looking at chronic pain and prescription opioid misuse noted that “there are considerable retrospective survey data that suggest that addiction is rare after opioid prescription for chronic pain” (http://hcp.lv/qD2vSs).

Another study, published by Fishbain, et al. in Pain Medicine in 2008 (http://hcp.lv/nz3UD7), involved a literature search to determine what percentage of chronic pain patients treated with long-term opioid analgesic therapy developed addiction and/or aberrant drugrelated behaviors. The authors reported that opioid analgesic therapy will lead to abuse or addiction in only a small percentage of chronic pain patients (3.2%), but a larger percentage will demonstrate aberrant drugrelated behaviors (11.5%). They also reported that the percentages are much smaller among patients who had no current or past history of abuse or addiction of alcohol or illicit drugs (0.19%).

Screener and Opioid Assessment for Patients with Pain (SOAPP)

This self-administered questionnaire “has been scientifically validated for use in chronic pain patients who are receiving, or under consideration for, long-term opioid therapy,” and can be used by clinicians to “better predict a patient’s likelihood of misusing or abusing opioids, document decisions about a recommended level of monitoring for a patient, and justify referrals to specialty pain clinics.” http://hcp.lv/mVnAwq

Screener and Opioid Assessment for Patients with Pain-Revised (SOAPP-R)

Although less sensitive and specific than the original SOAPP, the SOAPP-R provides “excellent discrimination between high risk and low risk patients,” and may be “an improvement over the original version in screening risk potential for deviant medication-related behavior among chronic pain patients.” One study suggests that is also “less susceptible to overt deception than original SOAPP.” http://hcp.lv/nVJ8dL

Opioid Risk Tool (ORT) The ORT is “office-based, 5-question

assessment designed to predict which patients may develop aberrant, drug-related behaviors based on known risk factors associated with abuse or addiction.” http://hcp.lv/mPm126

Diagnosis, Intractability, Risk, Efficacy (DIRE)

This clinician-administered instrument is designed to “screen for the appropriateness of long-term opioid therapy in patients with chronic noncancer pain, taking into account the likelihood of drug abuse, misuse, addiction, or drug diversion.” http://hcp.lv/n6tLUO

The authors of a literature review published in 2007 in the European Journal of Pain (http://hcp.lv/rtn0WG), intended to provide an overview of “definitions, mechanisms, diagnostic criteria, incidence and prevalence of addiction in opioid treated pain patients, screening tools for assessing opioid addiction in chronic pain patients and recommendations regarding addiction problems in national and international guidelines for opioid treatment in cancer patients and chronic non-malignant pain patients,” found wide variability in reported prevalence rates for addiction, “depending on the subpopulation studied and the criteria used.” The authors found that, in studies that identified addiction in patients based on behavioral criteria, prevalence varied from 0% to 50% in patients with chronic nonmalignant pain. In studies that defined addiction “based on criteria defined by the authors,” prevalence varied from 24% to 27.6%; in studies based on urine toxicology, prevalence varied from 17% to 39%. In their discussion of their findings, the authors wrote that the data from the literature review underscore the fact that “the diagnosis of addiction among chronic pain patients treated with opioids is difficult,” and that relying on the DSM-4 criteria “may tend to overestimate the problem.”

This observation is further confirmed by a recent study in the Journal of Addictive Diseases (http://hcp.lv/nhuEyc) that found there may be a higher prevalence of prescription pain medication addiction among chronic pain patients, at least as determined using the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for addiction. For the study, researchers identified and interviewed a random sample of outpatients (n=705) receiving treatment in a large health care system with long-term opioid therapy for non-cancer pain. Using criteria from versions 4 and 5 of the (DSM), the researchers concluded that the “prevalence of lifetime DSM-5 opioid-use disorder among these patients was 34.9%;” prevalence of lifetime opioid-use disorder was 35.5% using DSM-4 criteria. Opioid-use disorder was associated with age younger than 65, a history of opioid abuse and/or a history of substance abuse treatment, and more severe opioid withdrawal symptoms. Nearly 22% of patients in the study met the DSM-5 criteria for moderate opioid-use disorder; 13% met the criteria for severe opioid-use disorder. Perhaps the most interesting finding from the study was that, according to a news release that accompanied publication of the study, the new American Psychiatric Association definition of addiction, “which was expected to reduce the number of people considered addicts who take these medicines, actually resulted in the same percentage of people meeting the criteria of addiction” (http://hcp.lv/oeJpUn).

Addiction fears affect treatment

Despite this evidence to the contrary, patients’ and clinicians’ concerns and fears regarding opioid addiction continue to negatively influence treatment decisions. A survey conducted by the American Pain Foundation of primary care physicians, pain specialists, nurse practitioners, and physician assistants who treated chronic pain patients with opioid medications found that not only do clinicians’ “fears and misunderstandings about addiction greatly hinder use of opioid therapy,” these fears are “compounded by patient and provider confusion over addiction, tolerance, and physical dependence.” Survey results indicate that one-third (29%) of respondents reported that their prescribing habits are affected by their fear of patient addiction. Less than one-quarter of respondents (23%) agreed that “the clinical signs of tolerance and dependence are distinct enough from those of addiction.” Two-thirds of respondents said that they thought that physicians can differentiate between tolerance, dependence, and addiction in patients treated with opioids “only some of the time;” 12% said they believed that physicians can never differentiate between tolerance, dependence, and addiction. Nearly half (46%) of respondents claimed that they rely on “psychological and behavioral insight into their patients to understand/determine the extent of addictive behavior as opposed to applying addictive medicine practices.”

Screening and risk management

Preventing opioid abuse and misuse and minimizing the risk of addiction depends on the proper use of effective screening and risk management strategies in patients with chronic pain treated with opioid medications. As noted by this resource from the American Academy of Family Physicians (AAFP; http://hcp.lv/o1amsy), this begins with a physical exam and thorough history that includes “a family history and disclosure of any psychosocial risk factors,” such as a current or previous substance use disorder or familial history of substance abuse, and diagnosis of a major psychiatric disorder. Per the AAFP, there are “several different screening questionnaires that can be used in clinical practice to assess a patient’s potential risk for abuse and addiction,” including the Screener and Opioid Assessment for Patients with Pain (SOAPP), revised SOAPP (SOAPP-R), the Opioid Risk Tool (ORT), and the Diagnosis, Intractability, Risk, Efficacy (DIRE) questionnaire. Although these instruments are useful in identifying patients who may be at higher risk for abuse and misuse of their opioid medications, the AAFP guidelines remind clinicians that these tools “may give a false sense of security because even patients who score low on risk assessments may go on to misuse or abuse opioids. Therefore, it is important for physicians to be vigilant whenever they prescribe opioid therapy, even when the patient seems to be at lower risk of abuse. For patients who are identified as having a high risk for aberrant drugrelated behaviors, including those who have a history of drug abuse or psychiatric issues, it is appropriate to consider consulting with, cotreating the patient with, or referring the patient to a mental health or addiction specialist.”

After initiating opioid therapy, patients should be monitored for signs of aberrant behavior and addiction. One tool that is available that can help in this regard is the Current Opioid Misuse Measure (COMM), a 40-item questionnaire designed to help to identify risk potential for substance abuse that “primarily focuses on current behaviors and cognition rather than character and personality traits” (http://hcp.lv/pcU557). Aberrant behaviors that may indicate a patient is abusing or misusing opioids prescribed for chronic pain include unauthorized dose escalation, requesting early refills, using other opioids in addition to those prescribed, abnormal urine drug test results, etc. See Webster et al. (http://hcp.lv/pscT2e) and this resource from the National Institute on Drug Abuse (http://hcp.lv/oN9udq) for more examples. The “universal precautions” approach developed by Heit and Gourlay (http://hcp.lv/r3sEUN) offers a framework for the ongoing monitoring and assessment of chronic pain patients being treated with opioids. One of the tenants of this approach is the routine assessment of “the 4 As” of pain management: analgesia, activity, adverse effects, and aberrant behaviors.

As the brief examples in this article have shown, the evidence is that properly assessed and monitored chronic pain patients on opioid therapy face a much lower risk of addiction than is widely assumed by many clinicians and patients. Unsubstantiated fear of opioid addiction is a major contributor to undertreatment of pain. Despite some progress in this area, enhanced efforts to educate clinicians and patients about the true addiction risk associated with these medications are still needed.