CHAPTER 19: Evaluation for Opioid Management in Chronic Pain

ABSTRACT

Opioid analgesics provide effective treatment for noncancer pain, but many physicians have concerns about adverse effects, tolerance, and addiction. Misuse of opioids is prominent in patients with chronic pain, and early recognition of misuse risk could help physicians offer adequate patient care while implementing appropriate levels of monitoring to reduce aberrant drug-related behaviors. This is a brief review of opioid abuse and misuse issues that often arise in the treatment of patients with chronic noncancer pain and an overview of assessment and treatment strategies that can be effective in improving compliance with the use of prescription opioids for pain. Many persons with chronic pain have significant medical, psychiatric, and substance use comorbidities that affect treatment decisions, and a comprehensive evaluation that includes a detailed history, physical, and mental health evaluation is essential. Although there is no “gold standard” for opioid misuse risk assessment, several validated measures have been shown to be useful. Medical practitioners should regularly use urine drug screens to monitor adherence to long-term opioid therapy. Controlled substance agreements, regular urine drug screens, and interventions such as motivational counseling have been shown to help improve patient compliance with opioids and to minimize aberrant drug-related behavior. Finally, a discussion is presented of the future of abuse-deterrent opioids and other potential strategies for pain management.

INTRODUCTION

Chronic pain negatively impacts every facet of daily living. Chronic pain has been seen to interfere with quality of life by interrupting sleep, employment, social functioning, and many other daily activities. Patients with chronic pain typically report feelings of depression, anxiety, irritability, sexual dysfunction, and decreased energy. Often chronic pain adversely affects family roles and contributes to worry about financial limitations and future disability.^1-5

Studies analyzing factors affecting health and illness have shown that chronic pain is a widespread international problem.^6-8 More than 90 million Americans show symptoms of chronic pain, which is approximately one-third of the U.S. population. In the United States, chronic pain accounts for 21% of emergency department visits and 25% of annual missed workdays. Chronic pain is also responsible for up to $100 billion in annual direct and indirect costs, making it the most financially challenging condition to date.^9-12

Opioid analgesics have been used to help manage acute as well as cancer-related pain.¹³ This class of prescription medication is also used as a treatment for individuals with chronic noncancer pain; however, many physicians are reluctant to prescribe opioids for these patients because these medications contribute to adverse effects, tolerance, and addiction.¹⁴

The National Comorbidity Survey of Psychiatric Disorders collected epidemiologic data indicating a lifetime prevalence of 7.5% for drug dependence (illicit or prescription drugs) and 14.1% for alcohol dependence for individuals in the United States.¹⁵ Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV) results showed that approximately 3% of ...