page sections

Opioid Abuse and Addiction

last authored: April 2012, David LaPierre
last reviewed:

Introduction

Pain and addiction can co-exist. Addictions have a prevalence of 3-15%, with varying rates of drug, gender, etc.

Predisposition does not mean predestination.

Abuse of prescription medications has skyrocketed. The most common medications include:

opioids (oxycontin, percocet)
stimulants (ridalin)
benzodiazepines

There is a continuum of pain and addiction. Some patients sit in both camps.

When the drug is both the problem and solution, care can be made quite challenging.

Most patients don't need strict boundary setting, as they have their own internal set.

It is important to have a high index of suspicion for drug-seeking behaviour.

A single question -- "How many times in the past year have you used an illegal drug or used a prescripton medication for nonmedical reasons?" -- can effectively rule out drug abuse in a high prevalence population (Smith et al, 2010).

Death by overdose is now the 2nd most common cause of accidental death, after motor vehicle collisions, in Ontario (Sharon Baker, personal communication).

Addiction treatment is poorly funded.

Harm reduction strategies save lives. As drugs of abuse change, the methods of harm reduction need to change as well.

A huge level of this is iatrogenic.

Heroin was named for its heroic ability to suppress cough, patented by Bayer in 1898.

The Hague convention made it illegal in 1912, and a huge need for treatment arose. Morphine maitenance clinics were started, with the intent of controlling the amount and timing of opioid use.

Canada is the leading country in the world for opioid prescrptions (ref).

Universal Precautions in Pain Medicine

It is prudent to consider addiction in all patients.

Thoroughly inquire into drug and alcohol history in all patients.

ORT, CAGE, etc
set boundaries around medication use
identify aberrant behaviour

triage for risk

chronic pain patient
co-prescription of anti-depressants

When prescribing opioids

return to top

Dependence and Addiction

We need to use precise definitions around abuse, dependency, and addiction.

Addiction is a primary disorder, with continued use despite harm. An addicted enviroment's environment contracts with addiction.

Physical dependence is a state of adaptation...

Tolerance is a state of adaptation in which exposure to a drug induces changes that result in a decreased effect over time. Tolerance occurs as the body's signals state that

Pseudoaddiction is an iatrogenic misinterpretation of maladaptive behaviour resulting from inadequate pain control. This behaviour stops when adequate pain relief is provided.

Boundaries:

treatment agreements
urine testing
interval/contingency dispensing: provide fewer pills and frequent check-ins with pharmacist
pill counting when the bottle should be half full.

Addiction is a biopsychosocial issue.

One needs:

neurobiology, both genetics and acquired
psychology
env
availability
drug
reinforcement

People prefer oral, prescribed medications because:

return to top

Diversion

Most opioids on the street started as legal prescriptions that are then sold.

Patients divert for money, to support their own habit, or to fund other criminal activity.

return to top

Warning Signs

Be aware of the alarms and be forthright with addressing these.

"I don't like this other medication"
"I ran out early. Can I have some more?"
"I'm travelling. Can I have extra?"

Other warning signs include:

double doctoring
forged prescriptions
other medications in urine screening
concern from partner, family, friends
escalation of dosage by patient, without involving practitioner
increase the long-acting dose and continued levels of PRN dosing

Signs that are suggestive of addiction

selling, stealing, forgery
injecting
obtaining scripts from the street

Other considerations.

Comorbid psychopathology

Underlying primary addiction

Warning signs of drug abuse include:

multiple infections
abscesses
trauma: accidents, violence
mood changes: depression, anxiety, insomnia, etc
social changes: changes in relationships, job loss, financial troubles
weight loss
decreased libido

return to top

Discussing Addictions

It may be appropriate to discuss their addiction with the patient. You may ask about:

amount
pattern
route of use
consequences of use (social, legal, financial)
analgesic effectiveness
psychoactive benefits (decreased anxiety)
withdrawal symptoms
means of accessing

return to top

Prescribing Strategies

Universal precautions are important; this ensures patients, prescribers, and society are protected, particularly in regards to the inability to identify the 'at risk patient'

Do a physical exam for track marks

Ask about it, and do a history

Assess risk and use objective measures; the Partners against Pain

Trust instincts and prescribe rationally.

Use tight boundaries when needed.

Urine drug testing.

Get patients to bring in their medications when they come in for an appointment.

Ask the patients "What are you doing for your pain?", as looking to medications only is not ideal. Ensure they are trying to exercise appropriately, not damaging themselves further, caring for themselves, etc.

You need to provide a stable anchor for these patients.

If you people are running out; give them a higher dose but many less meds. If this does not work, bring in addictions medicine, but keep them as your patient.

Do not discharge patient if at all possible; they will now be free to wreak havoc in walk-in clinics/emergency departments.

If you set the box too tight, everyone will step out of bounds.

Set limits carefully from the outset. It is easier to loosen limits, rather than tighten them.

Treatment Agreement

avoid the term contract
must be readable, reasonable, and flexible
"to be filled only at this pharmacy"

Contract with patient that they do not change the dose on their own.

** get an example of this contract

One strategy is to call the patient and say 'I need you here today. Bring your pills.' and then count the medications to ensure they are not diverting.

If tolerance is an issue, one can:

increase dose
prescribe a drug holiday
cycle among drugs
augment

return to top

Urine Drug Screening

Urine drug screening (UDS) is cheap, effective, and well-tolerated. It is helpful to develop a relationship with the testing lab to assist in interpretation.

not helpful for complaince testing

return to top

Withdrawal

There are different levels

public intoxication: sobering unit
level I - home detox
level II - daytox: intensive day treatment
level III - non-medical residential withdrawal management; limited nursing and physician presence, but medicine protocols normally allowed
level IV - medically-managed residential withdrawal management; constant nursing presence, daily physician involvement
level V - acute care (eg hospitalization)

Supporting psychosocial factors, eg by providing daycare, can increase successful completion.

Further options include:

harm reduction, prevention and outreach
withdrawal management
intensive, ST, and LT residential housing

The stages of change model is important

Precontemplation, contemplation, and preparation: strengthen the mo

Harm reduction

needle exchange (strong evidence that this increases changes quit rates)
education
outreach programs
drug user peer networks

Prevention strategies build:

optimism
empathy
insight
intellectual competence
self-esteem
determination
direction or purpose (Kumpler et al, 1998).

Gastrointestinal

nausea
vomiting
diarrhea

Cognitive

anxiety
dysphoria
sleep disorder

Muscle and joint pain

Autonomic hyperativity:

rhinorrhea, lacrimation
hypertension, pallor
diaphoresis, tachycardia

Medications include:

clonidine 0.1mg PO QID, tapered
ibuprofen 200mg PO TID prn
loperamide 2mg PO BID prn
dimenhydrinate 50 mg PO q6h prn

Bupenorphine taper

partial agonist
very slow release from the brain
superior to other medications in treating withdrawal
relapse less likely

Overdose-related death is

Naltrexone can be used for maintenance, but it commonly causes dysphoria

return to top

Methadone

"According to guidelines issued by the World Health Organization (WHO), best practice in the 'psychosocially-assisted pharmacological treatment' of opioid dependence consists of methadone maintenance treatment, combined with one or more of a broad range of ancillary support services, such as counselling or contingency management.7 Despite methadone's proven effectiveness and affordability, methadone maintenance treatment is still unavailable in many low- and middle-income countries where it is desperately needed.12 Thus, expansion of treatment coverage to include more of the worlds' opioid users should be prioritized" (Wu and Clark, 2013).

Methadone has good success rates. It is not suitable for carries until stable, and their urine is clear, for daily dispensing for at least two months. Many patients stay on methadone life long and others will taper off.

There is ongoing criticism of methadone. There is huge unmet demand

Frequently there is no system srrounding methadone treatment.

Methadone was widely used in Germany as a pain mediaction, termed adophine. In 1962 it was started as a treamtent for 'morphinism'. Methadone maintenance treatment (MMT) was started in the 1960's in the 1960's, used for its 'heroin blocking effect'. Within Canada, political recommendation for expansion was made in the 1970s, though the Canadian Medical Association (CMA) came out strongly against the widespread use of methadone.

In many countries, methadone use has consistently expanded, though in Canada, use has declined.

Methadone can be used for maintenance of opioid abuse, as well as for detoxification.

17k for QALY (Sees et al, 2000).

Structured education for the health care providers is critical.

Dosing is important for long term success; doses of 60mg or more appear the most likely to be of benefit. However, the initial dose should be 30mg or less, related to difficult-to-predict differences in metabolism.

Every methadone quit effort increase the chances of success.

return to top

Bupenorphine

Lower rates of overdose

Retention is lower as compared to methadone

Preferred over methadone if:

Diacetylmorphine (heroin) lead to very significant outcomes in regards to retention and response (Oviedo-Joekes et al, 2009).

Causes death at much higher rates: