Discerning a Patient’s Potential for Non-Medical Use of Opioids

The United States is experiencing an increase of opioid related deaths, driven by high rates of prescription, high prescription dosages, and high rates of opioid use and misuse.[1] The National Institute on Drug Abuse reported that 2.6 million Americans over the age of 12 currently abuse either heroin or prescription pain relievers.[2] Unfortunately, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) Survey, the nonmedical use of prescription drugs now exceeds cocaine, heroin, hallucinogens, and inhalant abuse combined.[3] National and local policies alike have addressed the growing opioid epidemic by easing entry into treatment programs, advocacy, limiting the spread of infectious disease, and preventing overdose deaths.[4] Within the medical community, increasing physician awareness of opioid abuse is critical to limiting the circulation of prescription opioid analgesics. However, discerning the small minority of opioid users who are likely to succumb to opioid dependence presents a continuous challenge to controlling the entry of prescription opioids into nonmedical circulation.

Recently, several pieces of literature emerged that explore whether certain patient characteristics indicate a higher likelihood for noncompliance with opioid medication.

The indicators are a composite of lifestyle stressors and psychological factors; stressors have long been demonstrated to be linked to opioid abuse.[5] Literature on the social determinants of individuals who died from prescription opioids suggest that non-Hispanic Whites, American Indian/Alaska Natives, middle-aged individuals, rural residents, and those with a low socioeconomic status are disproportionately represented at a higher rate.[6] Keyes 2014 et al. investigated the intersecting of the other social determinants within a rural context and postulated that the lack of economic opportunity in rural areas have resulted in an older population with worse access to health infrastructure and greater chronic pain issues. These factors contribute to individual susceptibility to opioid use and abuse. Unfortunately, these findings do not go further in demonstrating that being a member of any vulnerable group likely to suffer from health disparities may be at increased risk for opioid misuse specifically.

Therefore, recently published research emphasize the link between pain behaviors and the non-intended use of prescription opioids, which find greater applicability in clinical settings. For instance, Cahill et al. 2017 refines this association by revealing the neurological and behavioural mechanisms (i.e. neuroinflammation) between stress, mental health, and opioid use; namely, patients who signify, through vocalizations or expressive pain behaviors are more likely to become reliant on opiates.[7], [8] Practitioners should watch for rubbing or habitual handling of affected areas of the body, catastrophizing of pain, vocalizations about the injustice of the pain, and facial grimaces. These signals are indications that the patient may be catastrophizing their pain in order to justify the continuous use of opioids.

For a health practitioner, it can be difficult to weigh these determinants against the easy solution of alleviating pain effectively and quickly. It can be even more difficult to explain, especially after exposure to aggressive marketing for prescription opioids, why they may want to try other pain management options. In these instances, anesthesiologists in their role as acute and chronic pain physicians play a critical role in offering alternative pain management regimens as well as emphasizing the side effects of opioids and are invaluable gatekeepers to patient access to serious narcotics.

[1] Florence CS, Zhou C, Luo F, Xu L. The economic burden of prescription opioid overdose, abuse, and dependence in the United States, 2013. Medical care. 2016 Oct 1;54(10):901-6.

[2] https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2016/americas-addiction-to-opioids-heroin-prescription-drug-abuse

[3] https://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf

[4] http://healthaffairs.org/blog/2015/09/22/stemming-the-tide-of-prescription-opioid-overuse-misuse-and-abuse/

[5] Front Matter A2 – al’Absi, Mustafa. In: Flaten MA, editor. Neuroscience of Pain, Stress, and Emotion. San Diego: Academic Press; 2016. p. iii.

[6] King NB, Fraser V, Boikos C, Richardson R, Harper S. Determinants of increased opioid-related mortality in the United States and Canada, 1990–2013: a systematic review. American journal of public health. 2014 Aug;104(8):e32-42.

[7] Cahill CM, Taylor AM. Neuroinflammation—a co-occurring phenomenon linking chronic pain and opioid dependence. Current opinion in behavioral sciences. 2017 Feb 28;13:171-7.

[8] Carriere JS, Martel MO, Kao MC, Sullivan MJ, Darnall BD. Pain behavior mediates the relationship between perceived injustice and opioid prescription for chronic pain: a Collaborative Health Outcomes Information Registry study. Journal of Pain Research. 2017;10:557.

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