REVIEWIssues in Long-term Opioid Therapy: Unmet Needs, Risks, and Solutions
Section snippets
THE ROLE OF OPIOIDS IN CHRONIC PAIN
Treatment options for chronic pain include nonpharmacological and pharmacological modalities. Choice of therapy should be guided by a comprehensive assessment, including history (eg, pain history, medical history, family history, psychosocial history, medications, past interventions), physical examination, and appropriate diagnostic studies. Underlying conditions, if present, such as a tumor or vertebral fracture causing spinal cord compression, should be treated as directly as possible while
RISK ASSESSMENT
If opioid therapy is considered for a patient, the risks of opioid abuse, misuse, and diversion should be carefully assessed. The object of risk assessment is to identify the likelihood that a patient will exhibit aberrant behaviors (eg, abuse, misuse, diversion, addiction; Table 223) once opioid therapy has been prescribed so that appropriate safeguards can be placed in his or her pain management plan.3, 24 Some patients are at greater risk for abuse, misuse, diversion, and addiction than
MONITORING
On the basis of risk assessment, patients can be stratified by their level of risk, and therapy can be structured appropriately to minimize risk and guide monitoring.6, 13 Patients at minimal risk can receive minimal structure, whereas those at greater risk can receive more structure, such as more frequent visits, fewer pills per prescription, specialist-level care (eg, an addiction specialist or psychotherapist), and UDTs. An opioid treatment agreement, discussed and signed by the patient
ABUSE-DETERRENT AND ABUSE-RESISTANT APPROACHES
Opioid formulations that incorporate barriers to common forms of manipulation are an emerging component of risk management. Novel subclasses of opioid formulations, incorporating pharmacological strategies and physical barriers, are designed to deter or resist misuse and abuse by making it difficult to obtain euphoric effects from opioid use. To obtain euphoric effects, most individuals who abuse opioids crush the tablets or capsules and snort or inject them, increasing opioid bioavailability.42
PHARMACOLOGICAL STRATEGIES
Pharmacological strategies have developed as either agonist-antagonist or agonist-additional active ingredient combinations. Agonist-antagonist formulations can be considered pharmacodynamic strategies because they act to reduce reward at the receptor level.43 An example of such a strategy is Embeda (King Pharmaceuticals, Bristol, TN), which combines morphine with an antagonist. If this formulation is ingested normally, the naltrexone remains latent; if it is crushed, the naltrexone is released
ABUSE-RESISTANT STRATEGIES
Abuse-resistant mechanisms use physical strategies that make extracting the active drug from its formulation more difficult. One such formulation is a controlled-release oxycodone, Remoxy (King Pharmaceuticals), formerly known as PTI-821, which sequesters oxycodone in a high-viscosity matrix. This investigational drug is intended to resist physical manipulation and chemical extraction used to alter drug delivery to unintended routes, such as injection, snorting, and other common methods of
CONCLUSION
Chronic pain and prescription opioid abuse are common and substantially affect patients, physicians, and society. Aggressive treatment of chronic pain must be balanced with the need to minimize the risks of opioid abuse, misuse, and diversion. Ongoing assessment can aid in developing a multimodal therapeutic plan, stratifying patients by risk, and identifying patients who may have aberrant behaviors after receiving opioid therapy. Not all aberrant behaviors have the same etiology, and thus
REFERENCES (51)
- et al.
Validation and clinical application of the Screener and Opioid Assessment for Patients with Pain (SOAPP)
J Pain Symptom Manage
(2006) - et al.
Nicotine and other substance interaction expectancies questionnaire: relationship of expectancies to substance use
Addict Behav
(2005) - et al.
Validation of the Revised Screener and Opioid Assessment for Patients With Pain (SOAPP-R)
J Pain
(2008 Apr) - et al.
Validation of a screener and opioid assessment measure for patients with chronic pain
Pain
(2004) - et al.
Sources of prescription drugs for illicit use
Addict Behav
(2005) - et al.
A new tool to assess and document pain outcomes in chronic pain patients receiving opioid therapy
Clin Ther
(2004) - et al.
Adding ultralow-dose naltrexone to oxycodone enhances and prolongs analgesia: a randomized, controlled trial of Oxytrex
J Pain
(2005) - et al.
Differences in prescription opioid analgesic availability: comparing minority and white pharmacies across Michigan
J Pain
(2005) NIDA Community Drug Alert Bulletin—Prescription Drugs
(2005)- et al.
Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse
Clin J Pain
(2006)
Direct costs of opioid abuse in an insured population in the United States
J Manag Care Pharm
Increasing deaths from opioid analgesics in the United States
Pharmacoepidemiol Drug Saf
Estimated costs of prescription opioid analgesic abuse in the United States in 2001: a societal perspective
Clin J Pain
Universal precautions in pain medicine: a rational approach to the treatment of chronic pain
Pain Med
Opioid guidelines in the management of chronic non-cancer pain
Pain Physician
Foundations of opioid risk management
Clin J Pain
Scribd Web site. Pain: current understanding of assessment, management, and treatments. 2001
Evidence report on the treatment of pain in cancer patients
J Natl Cancer Inst Monogr
The interface between pain and drug abuse the evolution of strategies to optimize pain management while minimizing drug abuse
Exp Clin Psychopharmacol
Pharmacologic management of chronic pain
J Am Osteopath Assoc
Opioid therapy in patients with a history of substance abuse
CNS Drugs
Use and abuse of opioid analgesics: potential methods to prevent and deter non-medical consumption of prescription opioids
Curr Opin Investig Drugs
PTI-821: sustained-release oxycodone using gel-cap technology
Expert Opin Investig Drugs
The use of opioids for the treatment of chronic pain: a consensus statement from the American Academy of Pain
Clin J Pain
The evolving and important role of anesthesiology in palliative care
Anesth Analg
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Dr Passik is a consultant for and on the speakers bureau of Cephalon, King Pharmaceuticals, Wyeth, and PriCara, a division of Ortho-McNeil-Janssen Pharmaceuticals.
This article is freely available on publication.