Preventing and Treating Opioid Abuse Amongst Chronic Opioid Therapy Patients

Prevention

Patients who have had a current or past history of addiction or any psychological problems (including abuse) are at higher risks for developing opioid misuse disorders and/or addiction during chronic opioid therapy. To best treat patients (whether they are at a higher risk for misuse/addiction or not), a multidisciplinary team is always recommended. One notable challenge in addressing chronic pain is that physical dependence does not always equate to addiction. With chronic opioid therapy, physical dependence should always be considered and even anticipated as a potential side effect. On the other hand, while not every person with chronic pain experiences emotional suffering, chronic pain is a well-documented cause of suffering. On average, 65% of patients with chronic pain have at least one chronic pain complaint, while 5-85% of patients with chronic pain also suffer from depression (For More info, see paper on Depression and Pain Comorbidity). Those who are experiencing emotional suffering may demonstrate concerning behaviors, including possible substance use disorders as opioids have a singular unique effect of relieving suffering. An individual will still experience pain and/or emotional distress, but the connection to emotional suffering is not as readily made. (For more info, see paper on Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies.)
The best way to prevent opioid abuse and misuse during chronic opioid therapy is to regularly monitor patients using universal precautions and follow all state and federal guidelines.
When opioids are diverted, they are typically taken at higher-than-prescribed doses or crushed so that the medication can be snorted, smoked, or injected. These routes result in faster delivery to the brain, leading to a more rapid and intense effect. Thus, abuse-deterrent formulations have been developed to minimize the chance that opioids will be misused. These strategies include:
- Combining opioid agonists with antagonists (such as oxycodone plus naloxone)
- Delivering the opioid pill in a form that cannot be crushed (such as the new formulation of OxyContin)
- Combining the opioid with a substance that triggers an adverse response. (https://www.nejm.org/doi/pdf/10.1056/NEJMra1507771)
Several mitigation strategies for assessment of opioid misuse have been proposed, including;
- Screening tools to identify patients with a substance-use disorder. Various questionnaires exist and are available to healthcare providers. Patients who score above a certain threshold may be at an increased risk for opioid abuse.
- Prescription Drug Monitoring Programs. Such data can be used to identify doctor shopping—a frequent indication of drug misuse or diversion.
- Urine Drug Screening can be performed before prescribing opioids and randomly during the course of therapy to provide information on drug use not divulged by the patient. For instance, if a urine drug screen returns negative for the medication in question, the patient is not taking their medication and may be diverting them.
- Doctor-patient agreements can help healthcare providers monitor a patient’s adherence to prescribed opioid medications. (For more info, see paper on Opioid Abuse in Chronic Pain — Misconceptions and Mitigation Strategies.)

Differentiating Chronic Pain Symptoms from Withdrawal Symptoms

As opioid withdrawal is associated with psychological distress / discomfort it can be difficult to differentiate the original, chronic pain, from any pain / discomfort caused by withdrawal. Further complicating the situation, withdrawal can increase baseline pain caused by other reasons (such as the chronic pain generator). So, not only do both the patient and healthcare provider need to evaluate possible withdrawal (and associated symptoms) after chronic opioid therapy, extensive discussion should take place as to what to anticipate if withdrawal occurs. While certain experiences of withdrawal (such as muscle ache which can mimic chronic lower back pain) are similar to distinct pain syndromes, other withdrawal experiences such as yawning, sweating and hot and cold flashes are likely to be solely associated with opioid withdrawal. Duration and severity of withdrawal-type symptoms are intimately related to both the duration of opioid therapy and which opioids were prescribed (i.e. oxycodone vs. fentanyl). (For more info, see paper on Opioids and the Treatment of Chronic Pain: Controversies, Current Status, and Future Directions.

How Opioid-Induced Hyperalgesia Can Make Chronic Pain Worse

Opioid-Induced Hyperalgesia is a situation where an individual experiences increased sensitivity to pain after exposure to opioids. This condition is almost paradoxical in nature, because the very opioids prescribed to treat chronic pain are what may cause the patient to suffer increased sensitivity to pain. Opioid-Induced Hyperalgesia is challenging to diagnose as the type of pain patient’s experience may be similar to their underlying pain symptoms, or may be very different than the original pain.

Patients and healthcare providers should suspect Opioid-Induced Hyperalgesia as a possible culprit when the pain-relief provided by a patient’s opioid regimen decreases despite no apparent disease progression. This is especially true if the decreased pain relief coincides with other unexplained pain symptoms or diffuse pain incongruent with the baseline pain complaint. There are some notable features to distinguish Opioid-Induced Hyperalgesia from progression of pre-existing pain and/or new pain due to injury. For the most part, pain associated with Opioid-Induced Hyperalgesia is more diffuse and less well defined in quality. For instance, a patient who suffers from chronic lower back ache may begin to complain of a throbbing sensation throughout their entire back and limbs. Opioid-Induced Hyperalgesia can even mimic pain typically associated with withdrawal and those suffering from Opioid-Induced Hyperalgesia may experience disproportionate pain to any new injury (a stubbed toe for example may feel significantly worse to someone suffering from Opioid-Induced Hyperalgesia than to someone who is not).

Treatment for Opioid-Induced Hyperalgesia first and foremost involves reducing or ultimately tapering off of opioid therapy. This absence of opioids allows the patient’s body to return to a more baseline status. If reduction and/or discontinuance of opioids is not an option, supplementations with medications known as NMDA-receptor modulators can help to alleviate some of the increased pain caused by Opioid-Induced Hyperalgesia. Increasing doses of opioids are not recommended for treating Opioid-Induced Hyperalgesia, as this can instead worsen the patients’ symptoms.

Unfortunately, concrete evidence as far as the prevalence of Opioid-Induced Hyperalgesia are not available at this time. Though, several studies have and continue to explore this condition and its significance.

For more information, see paper: A Comprehensive Review of Opioid-Induced Hyperalgesia