Prescription Opioids: Risk Management and Strategies for Safe Use _ _________________________________
COMMON MISCONCEPTIONS OF PAIN THERAPY WITH OPIOID ANALGESICS AND ADDICTION
Misconception or Belief
Correction
The tolerance and withdrawal of opioid dependence equates to opioid addiction.
Tolerance, withdrawal, and physiologic dependence are expected responses to opioids and other controlled substances when given in sufficient doses over time and are not, by themselves, indicative of addiction. Addiction is not an entirely predictable response to reward-producing drugs but may occur in biologically and psychologically susceptible individuals; it is diagnosed over time based on established criteria. Uncontrolled pain or anxiety and other psychiatric illnesses may trigger a relapse to substance use or exacerbate an existing disorder. Treatment should be tailored to patient need and may include alternative treatment modalities, monitored prescriptions, or other measures as needed. Patients with undertreated pain may engage in problematic behaviors that mimic opioid abuse but are driven by intense need for relief and resolve with adequate pain control. Many factors can underlie substance misuse, including varying cultural values, lack of education, misunderstandings, and poor judgment, that do not meet the criteria for a substance use disorder. Misuse does require evaluation for patient education and possible treatment modifications but does not mandate discontinuation of opioids. This has been proven false; the rate of iatrogenic opioid use disorder is low. Addiction is the result of individual susceptibility, and any opioid analgesic can be abused by predisposed individuals. An increase in pain severity can be countered by dose increase, switching to another opioid, or adding a non-opioid analgesic. After an effective dose is reached, many patients with chronic pain are able to maintain analgesia on the same dose. The initial sedation goes away within the first two weeks of initiation. Opioids have conclusively been shown to not hasten death in hospice patients; pain undertreatment is a far greater concern in hastening death.
Addiction can be accurately predicted and diagnosed in the initial assessment of patients with pain.
Medications for pain or anxiety should not be used in patients with a substance use disorder history.
Behaviors such as ‘‘clock-watching,’’ preoccupation with obtaining opioid analgesics, deception, stockpiling unused medication, and illicit substance use indicate addiction. Substance misuse is the same as substance abuse, dependence, or addiction; all require cessation of opioid prescribing.
Opioid therapy always leads to addiction.
Some opioids are worse than others in terms of addiction potential. If morphine is used now, there will not be options when the pain worsens. If I start taking an opioid, I will have to keep increasing the dose to control my pain. Morphine and opioids cause heavy sedation and probably hasten death.
Source: [15; 21]
Table 2
of administration was given the third highest rank- ing. Lowest ranked were unkempt patient appear- ance, sporadic unsanctioned dose escalation, and prescribed opioid hoarding [23]. There are certain behaviors that are suggestive of an emerging opioid use disorder. The most suggestive behaviors are [24; 25; 26]: • Selling medications • Prescription forgery or alteration
• Injecting medications meant for oral use • Obtaining medications from nonmedical sources • Resisting medication change despite worsening function or significant negative effects • Loss of control over alcohol use • Using illegal drugs or non-prescribed controlled substances
8
MDMS1526
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