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Chronic noncancer pain: Do patients abuse their opioids prescription?

Stephen Padilla
31 Oct 2018

Chronic noncancer pain can be treated with the use of opioid without necessarily causing addiction or abuse by the patient, according to a study presented at the Singapore Health and Biomedical Congress (SHBC) 2018.

“A small group of patients can benefit from use of opioids,” says Dr Yeo Sow Nam, director and consultant of The Pain Specialist at Mount Elizabeth Hospital and past president of the Pain Association of Singapore. “[T]horough diagnosis and patient history must precede opioids prescription.”

Unfortunately, there are those who end up abusing opioids, with more than 11.5 million people reported to have misused prescription pain medicine in 2016, according to Yeo. In addition, prevalence rates of aberrant behaviour, abuse and addiction are 40 percent, 20 percent and 2–5 percent, respectively. [Yeo SN, SHBC 2018]

The Liaison Committee on Pain and Addiction (American Society of Addiction Medicine) defines addiction using the 4Cs: impaired control over drug use, compulsive use, continued use despite harm (adverse consequences) and craving.

Moreover, Yeo defines abuse as “the nonmedical use of a drug, repeatedly or even sporadically, for the positive psychoactive effects it produces.”

Long-term opioid usage can lead to cognitive dysfunction, hormonal suppression, immune suppression, tolerance, opioid-induced hypersensitivity and addiction, Yeo says. In his presentation, he states that some prescription medication addicts even use doctors like dealers of illegal drugs.

Most users obtain prescription opioids free from a friend/relative (55.9 percent), followed by one doctor (18.0 percent), buying from a friend/relative (14.3 percent), drug dealer/stranger (4.3 percent), more than one doctor (2.4 percent), buying on internet (0.4 percent) and others (4.8 percent).

Interestingly, friends or relatives obtain prescription opioids from one doctor (81.7 percent). Other sources include the following: free from a friend/relative (6.2 percent), bought/took from friend/relative (5.4 percent), more than one doctor (3.4 percent), drug dealer/stranger (1.6 percent), bought on internet (0.1 percent) and others (1.6 percent).

Yeo differentiates a pain sufferer from an addicted patient. The former is not out of control with medication, uses medication to improve quality of life, is aware of side effects, concerned about medical problems, will follow the agreed treatment plan, and has medications left over from previous prescriptions.

On the other hand, an addicted patient is out of control with medications, has decreased quality of life due to medication misuse, wants medication despite side effects, is in denial about medical problems, does not follow the treatment plan, does not have medication remaining, and has always a ‘story’.

In a meta-analysis on the addictive potential of opioids, 24 studies including 2,507 chronic pain patients (CPPS) exposed show that the average percentage of reported addiction development on chronic opioid analgesic therapy (COAT) exposure is 3.27 percent, while the percentage of abuse/addiction in the selected group for no previous opioid exposure is 4.35 percent. [Pain Medicine 2018;8:444-459]

In 17 studies including 2,466 CPPs exposed, average percentage of aberrant drug-related behaviours noted on COAT exposure is 11.5 percent (average exposure time, 10.8 months).

Abuse deterrence, which refers to the “introduction of some limits or impediments to abuse in a drug formulation as opposed to the outright elimination of abuse,” is thus recommended, Yeo says.

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