Each month, Dr. Lynette Menefee tackles pressing issues in pain management with one of the nation's leading practitioners. This month, Dr. Menefee speaks with Dr. Robert N. Jamison of Brigham and Women's Hospital in Boston about the risks of addiction to opioids.

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Questions

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Dr. Lynette Menefee: Thank you for speaking with us today, Dr. Jamison. Our topic for this spotlight is pain and addiction. The problem seems to be summarized in this way:

Opioid medications are a main-stay for the treatment of moderate to severe pain. These medications can be and are abused. Is the risk of patient addiction worth prescribing these medications? That is, what are the consequences of using less or not using them at all?

Robert N. Jamison, Ph.D.: The general consensus is that opioid therapy can be safely administered to the vast majority of individuals with chronic pain. For this reason, it is usually acceptable to prescribe opioids for a chronic noncancer pain problem after more conservative treatments have been exhausted. However, we also know that between 5% and 15% of the general population are prone to an addiction disorder. Although pain specialists realize that patients with chronic pain use opioids differently than those without a pain problem, it is important to closely monitor individuals who are on opioids for pain in order to avoid an addiction problem.

LM: Okay. Given that these are important medications, what would you advise physicians who are concerned about increased scrutiny from regulatory agencies and prescribing opioids for patients who may ultimately abuse them?

RJ: Physicians should not worry about regulatory agencies monitoring their prescribing practices just as long as they carefully track the progress of each patient and document outcome. Documentation is the key. Each patient should complete an opioid therapy contract before being prescribed opioids for pain. Each physician should be responsible for periodically monitoring level of pain intensity, mood, activity, and any side effects or aberrant behaviors that may occur.

LM: Are there certain types of people more likely to abuse opioids? I mean, let's say a patient is the kind of person who seems to be focused on every aspect of pain and uses more opioid than prescribed because it is "needed." Is this person addicted?

RJ: I remember the 5 C's to help determine whether someone shows signs of an addiction disorder. They are chronic, compulsive use, impaired control, craving, and continued use despite harm. Unfortunately, there are some patients who feel that they are under treated for their pain and request more medication to help reduce the pain. They show some of the same aberrant drug behaviors as someone with an addiction disorder, however these behaviors disappear when their pain is more appropriately managed. This phenomenon has been described as pseudoaddiction.

LM: So, how can a physician or health care provider tell that a person is positively addicted? Are there cardinal signs?

RJ: There are no true ways to tell for sure whether some one has an addiction disorder. There are, however, a number of behavioral markers that can signal a problem. The noteworthy ones are prescription forgery, stealing or "borrowing" drugs from others, injecting oral formulations, obtaining prescription drugs from nonmedical sources, multiple dose escalations despite warnings, multiple episodes of lost prescriptions, repeatedly seeking prescriptions from other clinicians, evidence of deterioration in function at work or home, and repeated resistance to change therapy despite evidence of physical and psychological problems. Behaviors that may or may not signal a problem include frequent emergency phone calls and trips to the ER, concerns by significant others, complaining about the need for higher doses, and drug hoarding.

LM: Let's say that a person has a history of alcohol or drug abuse. Should this patient be treated with opioids for chronic pain?

RJ: Having a history of substance abuse should not automatically prevent a person from being prescribed opioids for pain. Although careful monitoring is indicated, many individuals who have a history of significant substance abuse problems can be appropriately maintained on opioids for pain.

LM: What about an active addiction? If an addict has acute pain, say from a surgery, how is the pain treated?

RJ: Having an active addiction can complicate things. First, individuals who are actively addicted have more problems in responsibly managing opioids than individuals who have been sober for many years and have been attending support programs such as Alcoholics Anonymous. Also, with an acute injury where treatment for postoperative pain would be needed, individuals with an ongoing substance abuse problem would likely have a higher tolerance to pain medication and may require more drug to treat the acute pain. This could add to the addiction problem.

LM: What if a physician finds out that a person with chronic pain has an active addiction? What are the options in this case? And how can you tell if a patient might be lying to you about an active addiction and using pain to obtain opioids?

RJ: Any physician who prescribes opioids for chronic pain should have the patient sign an opioid therapy agreement or contract. The contract should outline what is expected of each patient and can be helpful is deciding whether opioids should be discontinued. For instance, patients should be willing to submit to random urine screens. This can be one of the best ways to know if a patient is being compliant. An opioid contract can list other stipulations like avoidance of early refills, only getting medication from a single prescription source, and using a single pharmacy. Patients who are responsible with their medication often welcome an opioid agreement to help safeguard their treatment.

LM: What, if anything, does psychological assessment add to determining whether patients are at risk for abuse of addiction to opioids? Should all patients be assessed?

RJ: I think that a psychological assessment can be extremely helpful in identifying future problems and in recommending whether someone is a good candidate for opioid therapy or not. Currently the gold standard for opioid assessment is an in-depth mental health evaluation. Often the treating physician does not have time to identify important markers such as family history of addiction, impulsivity, past legal problems, psychiatric history, and other indicators of an addiction disorder such as whether a persons smokes a cigarette within the first hour of the day or not. Taken together, a picture can emerge of the likelihood for an addiction disorder. But, as I said, there is no way to be sure whether each individual will develop a problem or not. Currently there are a limited number of experienced mental health professionals who are familiar with pain management issues. As a result, not all patients can have access to a thorough psychological assessment. Our hope is that better self-report measures can be developed to screen individuals who are being considered for opioid therapy. This would be a useful way for physicians to determine which candidates would be best for chronic opioid therapy. There are a number of colleagues who are working on such a screening instrument right now.

LM: Thank you, Dr. Jamison. You have provided some insights on an issue that is of primary concern to physicians and health care providers.