Opioid abuse is a possible complication of the use of chronic opioid therapy for pain.
Reducing Opioid Abuse
Approaches to reducing the misuse of opioid medications:
- Let patients and families know that these medicines alone or in combination with other drugs, when used for non-medical reasons can have dangerous side effects and even result in death.
- Let patients and families know that there are legal consequences for diversion (sharing, selling, trading, or in any way providing opioid medications (or any controlled substance) to others).
- Physicians should monitor for appropriate use by checking urine for drugs prescribed and possible use of other illicit drugs and periodic checking of state Prescription Monitoring Program.
- Use early intervention strategies to assess risk and prevent progression to substance use disorders (e.g. take a good individual/family history for substance abuse problems, use Clinical Tools (e.g.: ORT, PHQ-9) to assess risk.
- Follow patients regularly for response to medications/appropriate use of medications. Consider opioid discontinuation and use other treatments if progress in regaining or improving function is not occurring.
Savage SR, Kirsch K, Passik S, Challenges in using opioid to treat pain in persons with substance abuse disorders. Addiction Science and Clinical Practice. June 2008.
Tracking Aberrant Drug-Related Behavior
Applying the DSM-IV TR criteria for opioid dependence to problem behaviors observed in those receiving chronic opioids for pain can be challenging. Making a diagnosis of opioid dependence (addiction) requires three of the following criteria to have been present in the last 12 months:
- Tolerance (expected as a normal response in those treated chronically with opioids)
- Withdrawal (expected as a normal response in those treated chronically with opioids if dose is suddenly decreased or stopped)
- Use of larger amounts of pain medications than intended
- Unsuccessful attempts to quit use
- Much time spent to obtain, use, recover from effects of drug
- Social, occupational, recreational activities given up in favor of drug use
- Use despite knowledge of negative consequences: worsening of physical or mental disorder, physically hazardous use, etc.
Adapted from American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC
Behaviors Indicative of Opioid Addiction
Diagnostic criteria can be challenging to apply to misusers of prescription opioid medications with chronic pain. For example, tolerance and withdrawal is expected with chronic opioid use. However, there are some behaviors, in addition to tolerance and/or withdrawal that are commonly observed that can meet criteria:
- Larger amounts than intended
- Much time in activities related to use
- Social, occupational, and recreational activities given up.
- Meeting these three criteria can make the diagnosis of opioid addiction (dependence).
The following behaviors may also be an indication of addiction to opioid pain medication
- Taking high doses and requesting increased doses
- Abuse of alcohol or other illicit drugs while taking opioid medications
- Runs out of medication early
- Appears to be intoxicated or experiencing withdrawal on evaluation
- Seeks additional opioid medications from family, friends, on the street, by internet, by emergency department visits
- Seeks specific drugs
- Uses opioid medications in a manner other than that prescribed (e.g.: crushes and sniffs or injects what should be taken as an oral medication)
- Reluctant to accept and engage in other treatments for pain
- Deterioration in functional status with ongoing opioid use
- Unauthorized dose increases
- Loss of prescriptions
- Angry, demeaning, or tearful if not given the drug requested
- Alters or steals prescriptions
- Doctor shopping
- Uses opioid for reasons other than that prescribed, e.g.: to relieve stress, help with sleep, following an altercation with another person, to get high