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Opioids in Clinical Practice

Outline

Opioid is the term used in clinical practise to describe drugs that act on opioid receptors, hampering the effective spread of pain stimuli, which results in the production of powerful analgesia. Opioid analgesics are the central treatment for moderate to harsh acute pain. The effective response to pain is therefore changed so that pain perception is maintained but the threshold of pain tolerance is amplified. Common opioids are morphine, codeine, pethidine, fentanyl, oxycodone and methadone. This article will be discussing the misperception that persons in pain receiving opioid analgesia are at increased risk of addiction, the dangers and consequences of this statement being accepted as fact and also what strategies need to be implemented in order to educate the public, patients, health care professionals and policy makers about this subject.

History

The background of opioids begins with the use of Opium, ‘the flower of happiness’, which was grown in the Middle East approximately 2000 years before the birth of Christ, and its use had become entrenched in India and China by AD 800. Opium was introduced to the Western world by the Swiss physician and alchemist, Philippus Paracelsus (1493–1541), who formulated Laudanum (tincture of opium) for treatment of pain. Today, farmers in the Australian State of Tasmania produce a large percentage of the Western world’s opium poppy (Papaver somniferum) from which opium alkaloid narcotics are formed (opiates). An opioid is any synthetic narcotic that has opiate-like characteristics 1).

Common Myths

There are many barriers and myths regarding the use of opioids, even though they remain the gold standard in pain management. The fear of addiction to opioid analgesics appears to be based on the widespread misconception that physical dependence is the same as addiction 2). This fear of addiction comes from years of half-truths about opioids, with some national antidrug campaigns also not paying attention to the medical benefits. In the past, official WHO definitions of drug abuse terms have equated addiction and drug dependence with physical dependence. Still, despite the fact that physical dependence is common in the treatment of cancer pain, the definitions have failed to regard that physical dependence can occur alone within a therapeutic setting 3). The risk of opioid addiction happening as a result of taking opioids for pain relief is rare («1%) 4).

Abuse and Addiction

The characteristics of abuse may include deception or illegal methods to acquire opioids. In many cases, fear of uncontrolled pain may cause the patient to raise the dose without consulting the prescribing medical doctor and may lead to eventual abuse and/or addiction behaviours. Characteristically, risk of addiction or abuse is lower for patients without a history of substance abuse than for those with such a history. Psychological evaluation and treatment for patients with a prior history of mental illness, including depression may also be beneficial 5).

The low rate of addiction among patients with cancer pain, the confusing nature of drug abuse terms, and the imprecise use of terms in both professional education and narcotic control laws has become an area of research and conversation 6). The potential for physical dependence and iatrogenic addiction is a historic and significant concern in opioid therapy. Physicians often are reluctant due to these factors, even though the risk is minimal. However, confusing categorisation surrounding dependence and addiction has weighed down the accurate assessment of these risks.

Physicians often confuse physical dependence, tolerance and psychological dependence. Typically, tolerance develops when a constant opioid dosage produces a declining effect, and opioid induced side effects. Opioid-induced physical dependence is a psychological phenomenon characterised by the progression of withdrawal syndrome when opioid therapy is stopped suddenly, when a reduction in dose occurs, or when an antagonist is administered. Anxiety, irritability, alternating chills and sweats and rhinorrhea can possibly be seen as early symptoms. Within one or two days after the abrupt cessation of opioid therapy, nausea and vomiting, abdominal cramps, insomnia and seizures may take place. These withdrawal symptoms are due to the autonomic nervous system becoming overactive when the CNS depressant effect of the opioid is suddenly removed. Addiction is identified by a continued craving for an opioid and a need to use opioids for effects other than that of pain relief 7). The obsessive search for a drug, the incapability to control the use of a drug, or for purposes other than pain relief, and sustained use despite adverse, psychological or social consequence can define psychological dependence. True addictive behaviour is seldom observed in patients with chronic pain who have no previous history of drug abuse 8).

Research On Substance Abuse

The World Health Organization Program on Substance Abuse was asked by the Pain Research Group at the University of Wisconsin Medical School to explain whether a physically dependent pain patient was considered to be drug dependent (or addicted). In reply, the WHO Expert Committee on Drug Dependence stated that indeed a cancer patient who is physically dependent (as indicated by a withdrawal syndrome) is not considered drug dependent. The demonstration of withdrawal syndromes in cancer patients given opioid analgesics is not by itself adequate evidence of dependence 9).

Increased regulatory scrutiny, the potential for drug diversion, and fear of patient addiction can make medical professionals reluctant to initiate opioid therapy on a long-term basis 10). The prescribing and supply of opioids is controlled by federal, state and local agencies. Controlled substances are shared with law enforcement and other regulatory organisations. These drugs monitoring programs have led to more than a 50% decrease in the prescribing of these medications 11). Well- publicised criminal prosecutions of clinicians who prescribe opioids for profit harmfully impact other providers’ risk in treating chronic pain with opioids. Media coverage of celebrities addicted to prescription opioids has negatively prejudiced public perception regarding to lawful use of these agents to manage pain 12).

Patient Outcomes

Patients continue to suffer pointlessly, primarily because of improper management and inadequate pain medication, despite the recent progress in the understanding of pain management. Physicians are anxious that their prescribing practices are examined by state and federal agencies and that their medical licence is at stake. Despite multiple attempts to educate the medical community, deficiencies in providing sufficient pain management have persisted 13). A clear understanding of the addictive potential or otherwise of opioids needs to be reached in order for effective treatment to take place. Although recent scientific advances have contributed to the neurobiology and photogenesis of addiction, there are different definitions of addiction utilised by the general public, regulatory, agencies and even among medical professionals 14).

Dependence Treatment

There are three techniques to treating opioid dependence. Stabilisation is usually by opioids replacement treatments, and aims to ensure that the drug use becomes independent of mental condition, such as craving and mood, and free of circumstances such as finance and physical location. The next stage is to withdraw from opioids. The final stage is setback prevention 15).

Failure to differentiate between addiction and physical dependence increases the risk that patients will not receive enough pain relief and will therefore suffer unnecessarily. It is common for people who are trapped between their concern about addiction and their desire to relieve pain that it is unimportant that the patients addicted because they are going to die anyway. This approach is totally inappropriate because it implies an incorrect definition of addiction, it unjustly labels the pain patient as an addict, and in any case will almost certainly not result in adequate pain relief because uncorrected knowledge about addiction and opioids will likely obstruct the kind of aggressive opioid therapy that some patients need. It is unfair to confuse a patient who may benefit from the medical use of opioids with a drug abuser. Concentrated efforts should be made to assure that the terminology used to describe drug abuse phenomenon in general usage, textbooks and narcotic control laws do not incorrectly affect the medical treatment of pain 16).

Administration

Prior to the commencement of administering opioid analgesia, a medical assessment should be conducted. The medical assessment should require that we do some more querying about things like past exposure or advance of hepatitis C, HIV, tuberculosis, sexually transmitted diseases, and alterations in the liver function tests. These kinds of abnormalities have an interesting connection with possible addictive behaviour. From a social history viewpoint, knowing about motor vehicle or fire related accidents, driving under the influence arrests, domestic, and even legal troubles may coincide with the use of various substances. Psychiatrically, it is vital to know if people have had problems with depression, anxiety, or what are often called personality disorders because they predispose people to want to cope with various substances as a way of self medicating 17). The patient should also show a failed response to first line treatments for chronic pain. The use of physical therapy, behavioural, and complimentary modalities should also be taken into account. When starting opioids the clinicians are recommended to start low and go slow and schedule regular patient visits to assess response to treatment. Clinicians must acknowledge their own biases and stereotypes and scrutinise each case critically to provide the best possible analgesia and minimise risk to both patient and professional practice 18).

Patients should be screened for the potential of drug abuse and be cautiously monitored for the duration of their treatment. It is important the health care providers be alert of possible signs of abuse 19). Health care providers should recognize and monitor for drug diversion mechanisms, which include: employees stealing from inventory, prescription forgery, robberies of pharmacies and drug distributors, ‘doctor shoppers’, health care providers (physicians, dentist, pharmacist), friend and family, illegal internet pharmacies, and illegal trafficking from foreign countries 20). The possibility for misuse, abuse and addiction should be addressed when considering long term opioid analgesic treatment. Assessing risk is not meant to deny high risk patients treatment for their pain but instead to match the degree of clinical monitoring to the degree of risk in order to reach better clinical outcomes and keep misuse to a minimum 21).

Due to these common misperceptions, the reluctance by medical professionals to prescribe opioid analgesia can have a widespread negative impact. Opioid therapy can relieve pain and improve mood and functioning in many patients in chronic pain and has led experts on pain to advise that such patients should not be denied opioids. Despite this recommendation, many physicians remain unsure about prescribing opioids to treat chronic pain. However, this seems to be a minority view 22).

Roles Of Health Professionals

The duty to battle pain and addiction are not equally exclusive, they are mutually inextricable 23). Many patients benefit from effective analgesia without serious side effects or addiction. Those at risk for substance abuse require extra structure, support, and monitoring to safely use opioid therapy. When prescribed appropriately in a dose enough to relieve pain, there is no sign that opioids lead to addiction . When clinicians believe that suitable use of narcotics leads to addiction, their unwillingness to prescribe these medications may result in chronic pain, which may lead to a long-term reliance on analgesics. Early use of narcotics, with tapering of the doses as pain is relieved, should be encouraged in controlling acute pain 24). The general finding is that patients with chronic pain not associated with a terminal disease can achieve satisfactory analgesia by using a steady dose of opioids with minimal risk of addiction 25).

Conclusion

This article has shown that to believe that patients who receive opioid analgesia are at greater risk for addiction is incorrect. If this statement is taken as fact, many patients will not receive the best possible treatment for managing acute pain, and will suffer more than is necessary. There is a need for medical professionals to be aware that there is a difference between tolerance, dependence and addiction. Patients that have prior history of drug abuse or mental illness are at greater risk of addiction, but physicians can control this with prior knowledge of such facts. A better education program is needed to raise awareness about this subject for all medical professionals, law and policy makers, patients, and the general public.

Pain Medicine | Health

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23) Webster, L.R., Webster, R.M., 2005, 'Predicting Aberrant Behaviours in Opioid-Treated Patients: Preliminary Validation of the Opioid Risk Tool', Pain Medicine, vol.6, pp432-442

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