May 23, 2007 National News Published Weekly

May 23, 2007 National News Published Weekly
Pain Treatment & Opioid Abuse
“Scientists Probe Ways to Curb Opioid Abuse With-out Hindering Pain Treatment,” an article in the cur-rent JAMA, says that research is beginning to “pro-vide some guidance” on the matter. The “skyrocket-ing numbers of prescriptions for opioid analgesics” and the abuse of the drugs dispensed in those pre-scriptions “has left many physicians considering the best ways to ensure that patients get needed pain relief while preventing abuse of pain medications.”
The National Institute on Drug Abuse (NIDA) recently sponsored a conference “to help advance research and interdisciplinary dialogue on the interface be-tween pain treatment and abuse of pain medica-tions.” Sessions presented at that meeting in March included research on ways to identify patients who may be substance abusers, techniques for prescrib-ing opioids safely and the development of painkillers that may be less addictive.
Dr. Nathaniel P. Katz, an analgesic researcher at Tufts University School of Medicine, says physicians need “to set up systems in their offices that support safe prescribing.” Elements of such systems include “use of tamper-proof prescription pads, quantitative urine analysis for all long-term opioid analgesic pa-tients at each visit, use of state prescription monitor-ing data for each patient when available and addic-tion screening for all patients followed by intervention and/or referral when appropriate.”
Psychologist Steven D. Passik of Memorial Sloan-Kettering Cancer Center says physicians “should establish structured monitoring for their analgesic patients, starting with an assessment of their risk of developing a substance abuse problem.” Passik says that substance abuse is often linked with abuse of prescription painkillers. The article cites one study that “found that the patients with a history of sub-stance abuse were more than twice as likely to report aberrant drug-taking behaviors than the patients without such a history.”
Passik also suggests that “physicians should triage patients into appropriate treatment regimens based on their risk of developing an addiction. … For ex-ample, patients at low risk of addiction might be pre-scribed a long-acting opioid analgesic to control chronic pain and a short-acting analgesic to be used at their discretion to control breakthrough pain, and they may be asked to undergo infrequent urine tests. High-risk patients would be required to have frequent urine tests and would likely receive only a long-acting analgesic.”
The article says, “All patients taking prescription an-algesics should be regularly assessed for effective-ness of treatment and the presence of negative out-comes.” Passik and others have developed the Pain Assessment and Documentation Tool, which meas-ures “whether patients are receiving adequate anal-gesia, experiencing improvements in psychosocial function or activities of daily life, experiencing any adverse effects, and persistently participating in ab-errant medication-taking behaviors that may be linked to addiction.”
When assessments reveal difficulties in any areas, physicians should intervene and “adjust treatment regimens.” This is particularly important, the author says, for the “30% to 40% of patients who do not re-spond to opioids.” For those patients, Katz recom-mends adjusting the dosage, adding an additional analgesic, prescribing physical therapy, arranging for a psychological consultation, or switching to a differ-ent opioid. If there is still no response, “rehabilitation therapies, physical modalities such as ice or heat, psychological therapies such as cognitive behavioral therapies, or complementary medicine” may be used. Katz calls these therapies “evidence-based and effi-cacious,” but says they are “less commonly used, in part because they are less aggressively marketed and may not be covered by insurance.”
Physicians should try to determine why patients are “exhibiting aberrant drug-taking behaviors.” Possible reasons include addiction, inadequate pain relief on the current prescription, a comorbid mental illness or diversion of the prescription.
Scientists are working to develop better formulations of opioid medications. Many opioids are poorly ab-sorbed when taken orally, so their formulations have very high levels of the drugs. Patients who abuse the drug can get up to as much as three times the oral amount by crushing, dissolving and injecting the drug. Extended-release formulations have the same effect, with snorted or injected drugs providing a very high dose of the opioid, one not received by the pa-tient who takes it as prescribed. Some manufactur-ers are working on pills to be given sublingually that deliver more than 90% of the prescribed medication, while others are working on abuse-resistant gel for-mulations that “cannot be circumvented by crushing the capsule, heating it, or mixing it with alcohols.” Still another method of avoiding abuse is the mixing of opioid antagonists to prescription opioids, which may block the pleasant sensations associated with abuse or produce unpleasant effects if not taken as prescribed.
Katz says, “There are a lot of things we don't know about opioids, and there are a lot of things we do know but can't implement.” “Physicians interested in helping patients with chronic pain,” Katz also says, “should support legislation aimed at boosting insur-ance reimbursements for nondrug pain treatments, encourage funding agencies to back practical clinical studies, and help develop straightforward, evidence-based guidelines for opioid prescribing.”
The webcast from the March session can be viewed at www.nida.nih.gov. Click on the link under “Pain, Opioids and Addiction.” (JAMA, 2007;297:1965-1967; NIDA Website)