Screening for Problematic Prescription Opioid Use

Department of Psychiatry, University of Texas Southwestern Medical Center at Dallas, 75390, USA.
Clinical Journal of Pain (Impact Factor: 2.53). 10/2001; 17(3):220-8. DOI: 10.1097/00002508-200109000-00006
Source: PubMed


The proper medicinal use of opioids, in light of their notorious history and current relation to social ills, continues to be debated and remains unclear in several areas of medicine. This article will review several areas and points of controversy related to screening for potential problematic opioid behavior in chronic nonmalignant pain patients. Controversy over the prescription of opioids for chronic nonmalignant pain continues, despite the growing acceptance of this practice. Indeed, past research supports the beneficial use of opioids for noncancer pain. Unfortunately, traditional definitions of abuse and dependence, with their emphasis on tolerance and withdrawal, are inappropriate for chronic pain patients prescribed opioids. The component of traditional definitions of abuse and dependence that appears most applicable to chronic pain patients centers on the criterion that the patient continue to take the drug (in this case, the opioid) despite negative and harmful effects or despite any decrease in pain level. Although clinical observations exist about risk factors for opioid misuse in chronic pain patients, there is limited research. Further, the area of prescreening for problematic drug behavior is in its infancy. However, researchers have begun to delve into this challenging area and the application of rigorous empirical research will bring us closer to identifying those patients at risk so that their pain is managed without destructive outcomes in other areas of their life.

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    • "Opioid escalation can occur for a variety of reasons, including underlying disease progression, addiction, and pharmacologic tolerance. There are diagnostic tools to identify disease progression, and there are guidelines to identify and manage pain patients who might be drug-seeking or have a history of substance abuse [7]. However, there are not yet any guidelines to identify patients who may be poor candidates for long-term opioid treatment because they are prone to rapid opioid tolerance development that would make long-term pain relief unsustainable. "
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    ABSTRACT: Thyroid hormones are essential for the maturation and functions of the central nervous system. Pain sensitivity is related to the thyroid status. However, information on how thyroid hormones affect pain processing and synaptic transmission in the anterior cingulate cortex (ACC) is limited. Nociceptive threshold and synaptic transmission in the ACC were detected in the experimental hypothyroidism (HT) mice. HT was induced by methimazole and potassium perchlorate in distilled drinking water for 4 weeks. The threshold of pain perception to hot insults, but not mechanical ones, decreased in hypothyroid mice. After treatment with tri-iodothyronine (T3) or thyroxine (T4) for 2 weeks, thermal pain threshold recovered. Electrophysiological recordings revealed enhanced glutamatergic synaptic transmission and reduced GABAergic synaptic transmission in the ACC. Supplementation with T3 or T4 significantly rescued this synaptic transmission imbalance. In the same model, HT caused the up-regulation of the GluR1 subunit of the α-amino-3-hydroxy-5-methyl-4-isoxazolepropionic acid receptor and NR2B-containing N-methyl-D-aspartate receptors, but it down-regulated γ-aminobutyric acid A receptors in the ACC. Supplementation with T3 or T4 notably recovered the levels of above proteins. These results suggest that HT promotes hypersensitivity to noxious thermal, and that supplementation with T3 or T4 rescues the imbalance between excitatory and inhibitory transmission in the ACC.
    Molecular Pain 05/2012; 8(1):38. DOI:10.1186/1744-8069-8-38 · 3.65 Impact Factor
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    • "It is important for clinicians to examine several factors, including a patient's age and gender, to provide the best clinical assessment and treatment for the patient. There is evidence to suggest that younger individuals who are prone to impulsivity have a greater risk for misuse of opioids [30, 35, 36]. One recent study of gender differences and opioid misuse suggested that women are at greater risk for misusing opioids due to emotional issues and affective distress, while men tend to misuse opioids due to legal and problematic behavioral issues [37]. "
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    ABSTRACT: Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic back pain and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. In this review, we discuss opioid abuse and misuse issues that often arise in the treatment of patients with chronic back pain and present an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic back pain have significant medical, psychiatric and substance use comorbidities that affect treatment decisions and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no "gold standard" for opioid misuse risk assessment, several validated measures have been shown to be useful. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, we discuss the future of abuse-deterrent opioids and other potential strategies for back pain management.
    Pain Research and Treatment 10/2011; 2011(2090-1542):941808. DOI:10.1155/2011/941808
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    • "Other measures include the Screening Instrument for Substance Abuse Potential (SISAP; Coambs et al., 1996), the Pain Assessment and Documentation Tool (PADT; Passik et al., 2004) and the Pain Medication Questionnaire (PMQ; Adams et al., 2004). While the authors of these measures report that some items distinguish patients currently abusing their medications from those who are not abusing their medications, none have undergone prospective testing such as that recommended by Robinson et al. (2001), and no one scale has been determined to be superior in assessing opioid abuse (Butler et al., 2004). No tool was developed exclusively for continued assessment of current opioid use. "
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    ABSTRACT: Clinicians recognize the importance of monitoring aberrant medication-related behaviors of chronic pain patients while being prescribed opioid therapy. The purpose of this study was to develop and validate the Current Opioid Misuse Measure (COMM) for those pain patients already on long-term opioid therapy. An initial pool of 177 items was developed with input from 26 pain management and addiction specialists. Concept mapping identified six primary concepts underlying medication misuse, which were used to develop an initial item pool. Twenty-two pain and addiction specialists rated the items on importance and relevance, resulting in selection of a 40-item alpha COMM. Final item selection was based on empirical evaluation of items with patients taking opioids for chronic, noncancer pain (N=227). One-week test-retest reliability was examined with 55 participants. All participants were administered the alpha version of the COMM, the Prescription Drug Use Questionnaire (PDUQ) interview, and submitted a urine sample for toxicology screening. Physician ratings of patient aberrant behaviors were also obtained. Of the 40 items, 17 items appeared to adequately measure aberrant behavior, demonstrating excellent internal consistency and test-retest reliability. Cutoff scores were examined using ROC curve analysis and reasonable sensitivity and specificity were established. To evaluate the COMM's ability to capture change in patient status, it was tested on a subset of patients (N=86) that were followed and reassessed three months later. The COMM was found to have promise as a brief, self-report measure of current aberrant drug-related behavior. Further cross-validation and replication of these preliminary results is pending.
    Pain 08/2007; 130(1-2):144-56. DOI:10.1016/j.pain.2007.01.014 · 5.21 Impact Factor
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