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Evidence-Based Reviews


Prescription opioid use disorder: A complex clinical challenge

Understanding patients’ aberrant medication-taking behaviors can greatly aid treatment

Vol. 11, No. 08 / August 2012

Discuss this article at www.facebook.com/CurrentPsychiatry

You’ve been treating Mr. H, a 54-year-old factory worker and tobacco user, for depression that developed after a work-related back injury and subsequent disability. His depression has had a fair response to an antidepressant. He also has been maintained on chronic opioids (morphine and oxycodone/acetaminophen) for 18 months by his primary care physician (PCP). At the end of your appointment, he asks you for a refill of the opioids because he “ran out” early because of increased night pain and resultant insomnia and “stress.” He clarifies he has asked for early refills before from his PCP, but lately he has been denied. Because you “seem to listen to me more,” he asks for your help. How should you manage Mr. H?

Opioids are among the most commonly misused prescription drugs in the United States.1 In 2008, poisoning was the leading cause of death from injury in the United States; roughly 90% of poisonings resulted from drug exposure, and >40% of these drug poisonings were from prescription opioids.2 The Centers for Disease Control and Prevention estimates that the number of emergency department (ED) visits for nonmedical use of opioids increased 111% between 2004 and 2008, from 144,600 to 305,900 visits.3 The highest number of visits were for use of oxycodone, hydrocodone, and methadone.3

Increased prescribing of opioids and overdose deaths attributable to prescribed opioids have raised concern among physicians about how to effectively treat pain as well as prevent, recognize, and manage aberrant medication-taking behaviors (AMTBs). Psychiatrists are well-positioned to screen and manage their own patients for prescription opioid use disorder (POUD) or collaborate with opioid prescribers to accomplish the same.

Clarifying terminology

Terminology used to describe POUD and related conditions often is poorly defined or loosely applied. Because emotions often enter discussions between patients and physicians about problems related to opioid therapy, nonstigmatizing and more objective terminology is needed, and clinicians are working toward standardizing this. Relevant terms are defined in Table 1.4

The DSM-5 Substance Use Disorders Work Group has proposed using the term opioid use disorder (OUD) to replace the term opioid dependence.5 The hope is that removing the word “dependence” from the diagnostic term will reduce confusion between “dependence” due to expected physical dependence (tolerance, withdrawal) on medically prescribed opioids vs true addiction (currently defined as “opioid dependence” in DSM-IV-TR). This Work Group also has proposed combining opioid abuse and opioid dependence criteria into a single diagnosis of OUD, and adding “craving” to the criteria. For the complete proposed criteria, see www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=460.These changes are still under review. In this article, we use the term POUD.

Table 1

Terminology related to prescription opioid use disorder

Term

Definition

Chronic paina

Pain that extends beyond the expected period for healing (6 months), initiated by tissue damage, but perpetrated by the interaction of physiologic, affective, and environmental factors

Chronic nonmalignant paina

Chronic pain associated with diverse diagnoses and syndromes that are not terminal but affect the patient’s function

Appropriate usea

Taking a prescription as prescribed, and only for the condition indicated

Misusea

Taking a prescription for a reason or at a dose or frequency other than for which it was prescribed; this may or may not reflect POUD

Drug-seeking behaviors

Patient behaviors directed toward obtaining controlled substances, driven not by amelioration of the condition for which the medication was indicated but rather by other maladaptive gains; this may or may not reflect POUD

Chemical coping

Taking a controlled substance medication to relieve psychological problems (eg, to relieve low mood, anxiety, insomnia) and for reasons other than the purpose for which it was prescribed; this may or may not reflect POUD

Aberrant medication-taking behaviorsa

Taking a controlled substance medication in a manner that is not prescribed; causes for this may include:

  • lack of understanding about how to take the opioid appropriately
  • external pressures, such as to give to another person for his or her pain
  • chemical coping
  • pseudoaddiction (see below), including:
  • addiction or substance use disorder (such as POUD)
  • diversion

Pseudoaddiction

An iatrogenic syndrome of “addiction-like” behaviors in which the patient seeks opioids to relieve pain—such as seeking different doctors, self-adjusting the opioid dose, early refills of opioids, etc.—rather than to achieve pleasure or other nonpain-related effect. At times mistaken for true addiction, these behaviors tend to resolve and function improves once analgesia is better addressed

a These terms and definitions are adapted from reference 4. The remaining terms and definitions were developed by the authors
POUD: prescription opioid use disorder

POUD and chronic pain

The incidence of POUD during opioid therapy for pain is unknown.6 Some researchers have suggested it may be as low as 0.2%,7 while others estimate that rates of POUD in patients with chronic pain may be similar to those in the general population: 3% to 16%.8 When applying the proposed DSM-5 criteria to patients receiving long-term opioid therapy for noncancer pain, the lifetime prevalence of POUD may be as high as 35%.9

Prescribers may be contributing to POUD. Roughly 76% of opioids used for nonmedical purposes were prescribed to someone else, 20% were prescribed to the user, and 4% came from other sources.1 Strategies to reduce POUD risk may be underused. In a retrospective cohort study of 1,612 patient electronic medical records from 8 primary care clinics that managed patients with long-term opioids for chronic noncancer pain (average prescribing duration of 2 years duration, ≥3 monthly prescriptions in 6 months), researchers evaluated how often prescribers used 3 risk reduction practices:

  • urine drug tests
  • regular office visits (≥1 every 6 months and within 30 days of changing opioid treatment)
  • restricted early refills (≤1 opioid refill more than a week early).10

Risk factors for opioid misuse included age <45, having a substance use disorder or other psychiatric disorder, and using tobacco. Only 8% of all patients received a urine drug test, only one-half had regular office visits, and 23% received >1 early refill. Researchers found that even for high-risk patients, these strategies were used infrequently. Less than one-quarter of patients with ≥3 risk factors ever had a drug test, and those at increased risk were more likely to receive >1 early refill but no more likely to have more frequent visits. Issues such as patient entitlement, lack of physician education, and time constraints may explain why these strategies are not used more often.11

No one procedure or set of variables is sufficient to identify chronic pain patients who may be at risk for POUD. However, a history of drug or alcohol use disorders may be a significant risk factor.12,13

Few tools have been developed to help identify those at risk of AMTBs or POUD, and all have limitations.4,14 Recommended self-report measures include the Current Opioid Misuse Measure and the Opioid Risk Tool.15 A review of studies in which these kinds of tools were developed revealed limited evidence for their use; most studies had methodological shortcomings, did not use standardized AMTB criteria, and provided little assessment of whether these tools changed clinician behaviors or improved patient outcomes.16

Evaluating AMTBs

Although diagnosing POUD in pain patients receiving chronic opioids can be challenging, assessing for AMTBs typically is helpful. Once AMTBs are identified, they can be examined to determine what drives their expression (Table 14 and Table 217). However, often it is easier to identify AMTBs than to interpret their origins; as much as 30% to 50% of patients who complain of chronic pain may have primary substance dependence to sedatives, opioids, or both.11

Table 2

Aberrant medication-taking behaviors and POUD risk

Behaviors more suggestive of POUD

  Deterioration in function (work, social)

  Illegal activities (selling medication, forging prescriptions, buying from non-medical sources)

  Altering the route of administration (snorting, injecting)

  Multiple episodes of ‘lost’ or ‘stolen’ prescriptions

  Resistance to change therapy despite negative outcomes

  Refusal to comply with toxicology testing

  Concurrent, active abuse of alcohol, illegal drugs

  Use of multiple physicians or pharmacies to obtain the prescription

Behaviors less suggestive of POUD

  Complaints for more medication

  Medication hoarding

  Requesting specific pain medications

  Openly acquiring similar medications from other providers

  Occasional unsanctioned dose escalation

  Nonadherence to other recommendations for pain therapy

POUD: prescription opioid use disorder
Source: Reference 17

Although AMTBs are common among chronic nonmalignant pain patients,18,19 how often AMTBs reflect underlying POUD is uncertain.7 It is critical to interpret AMTBs with a balance of caution and care: “react therapeutically, not punitively.”20 Categorizing a patient’s AMTB as more or less likely to support a POUD diagnosis can be helpful, but is not conclusive (Table 2).17 Clinical correlation often is required. No single AMTB alone is indicative of POUD. When evaluating AMTBs, the treating provider should use a nonjudgmental stance, and consider obtaining collateral data from people who can provide differing perspectives of the patient’s behaviors, such as other clinicians, significant others, family, etc. (a release of information from the patient may be required). Another source of collateral data is prescription monitoring databases. These databases typically are state-based and provide electronic access to prescription information, allowing you to search for patterns—ie, use of multiple prescribers or pharmacies, undisclosed prescriptions, etc. Interest in establishing a single, federal database has been increasing, but striking a balance between carefully monitoring for AMTBs and protecting privacy remains unresolved.

DSM-IV-TR diagnostic criteria for opioid dependence21 can be challenging to interpret in patients who are prescribed opioids for pain (Table 3).6 To clarify interpretation, the Liaison Committee on Pain and Addiction of the American Society of Addiction Medicine (ASAM) has provided an outline of possible indicators of addiction in pain patients (Table 4).6 This was a consensus statement from the American Pain Society, the American Academy of Pain Medicine, and ASAM.

Assessment is primarily clinical and requires an awareness of appropriate terminology, an index of clinical suspicion, and expertise teasing apart pain, addiction, and pseudoaddiction. In our experience, it is helpful to ask a chronic pain patient whom you suspect might have POUD, “Have you ever used your prescribed opioids for reasons other than improving function or reducing pain, such as for getting a ‘high,’ managing stress, escaping from problems, etc.?” An affirmative response suggests an underlying problem with use of prescribed opioids, indicating a need for more careful questioning to determine if AMTBs or POUD coexist with chronic pain.

Drug testing can help determine if a patient is taking opioids that are not prescribed—as well as illicit drugs or alcohol—and confirm the presence of those that are prescribed. Toxicology screening should include opioids typically screened for (eg, morphine, codeine, heroin) and those for which additional tests may be required (eg, semi-synthetics such as oxycodone and hydrocodone and synthetics such as fentanyl).

Table 3

Identifying addiction in pain patients: Limitations of DSM-IV-TR

DSM-IV-TR substance dependence criteria

Challenges in using criterion to diagnose prescription opioid use disorder

Tolerance

Expected with prolonged opioid compliance

Physical dependence, withdrawal

Expected with prolonged opioid compliance

Use of larger amounts or longer than initially intended

Emergence of pain may demand increased dose or prolonged use

Multiple failed attempts to cut down or control

Emergence of pain may deter dose reduction or cessation

Time spent finding, using, or recovering

Difficulty finding adequate pain treatment may increase time spent pursuing analgesics. However, time spent recovering from overuse may suggest addiction

Given up or reduced important activities

Valid criteria—engaging in activities is expected to increase, not decline, with effective pain treatment

Continued use despite knowledge of negative consequences

Valid criteria—no harm is anticipated from analgesic opioid use for pain (see Table 4)

Source: Adapted from reference 6

Table 4

Possible indicators of addiction in pain patients

ASAM-APS-AAPM behavioral criteria

Examples of specific behaviors in opioid therapy for pain

Impaired control over opioid use

Patient requests early refills, frequently reports loss or theft of medication. Withdrawal noted at follow-up appointments despite having an adequate quantity of medication prescribed

Continued use despite harm from opioids

Patient exhibits declining function, opioid intoxication, persistent oversedation from opioids

Preoccupation with opioids

Patient ignores non-opioid interventions for pain, makes recurrent requests for opioid dose escalation (or complains of increasing pain) despite absence of disease progression or despite opioid dose increase by provider

AAPM: American Academy of Pain Medicine; APS: American Pain Society; ASAM: American Society of Addiction Medicine
Source: Adapted from reference 6

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