Opioid Dependence: Managing the High Cost of Treatment Failure

Abstract

BackgrOunD: The use of opioids for chronic noncancer pain increased 222% from 1992 to 2002. Opioid dependence has also increased significantly, leading to a burden on patients, employers, insurers, society, and the entire health care system. It is imperative that opioid dependence is addressed and treated properly, in order to return patients to being productive participants in the workplace and society. OBjecTIve: To provide an overview of addiction, abuse, and dependence and identify risk factors for addiction. Summary: Studies have shown that intensive use of opioids is associated with increased utilization of costly health care services, prolonged disability, and continued use of opioids, leading to abuse and dependence in many patients. While identifying patients at risk for developing opioid dependence is difficult, there are many risk stratification tools now available to practitioners, including the Opioid risk Tool (OrT) or Screener and Opioid assessment for Patients with Pain (SOaPP). understanding the differences between dependence, addiction, and tolerance is essential to managing patients on opioids. cOncLuSIOn: It is imperative that patients be properly managed when being treated for pain. Physicians and employers have to be able to identify patients at risk for opioid abuse or exhibiting symptoms of opioid abuse and know how to address their needs. J Manag Care Pharm. 2010;16(1-b):S4-S8 copyright © 2010, academy of managed care Pharmacy. all rights reserved. SAIRA A. JAN, MS, PharmD, is Clinical Director, Blue Cross Blue Shield of New Jersey, and Associate Professor at the Ernest Mario School of Pharmacy of Rutgers, the State University of New Jersey. AUTHOR CORRESPONDENCE: Saira A. Jan, MS, PharmD, Director of Clinical Pharmacy Management, Horizon Blue Cross Blue Shield of New Jersey, Newark, NJ 07105-2200. Tel.: 973.466.6192; Fax: 973.466.4665. E-mail: Saira_ Jan@horizon-bcbsnj.com. Author Drug abuse and dependence are on the rise. The widespread use of opioid analgesics for the treatment of chronic noncancer pain and for acute pain management began in the late 1980s. Between 1980 and 2000, there was an increase from 8% to 16% in the number of patients receiving opioids for chronic musculoskeletal pain and an increase in use from 8% to 11% for acute musculoskeletal pain.1,2 In 2002, reports show a 222% increase in the absolute number or prescriptions for opioid narcotics over the previous 10-year period.1,3 Today, the most common method for treating chronic pain is with the use of prescription analgesics, including opioids.4 In the 1970s, chronic pain patients were encouraged by society to avoid opioids due to concerns that taking opioids invariably led to addiction.5 In the early 1980s, the pendulum shifted to widespread use of opioids, based on results of a small study (n = 20) showing chronic pain patients could benefit from pain control using opioids with little risk of developing dependence.6,7,8,9 Additionally, in the 1990s, a review article of several studies showed patients with neuropathic pain experienced relief from opioids.6,8,9 Unfortunately, many patients continue to take opioids despite inadequate pain control. Patients on chronic narcotic pain medications generate higher costs of health care, have higher surgery rates, a greater level of disability, and higher rates of late opioid use.10 Late opioid use is defined as receiving ≥ 5 opioid prescriptions between 30 and 730 days after onset of pain, a quantity of prescriptions that is generally beyond what is considered appropriate use for symptom control for an acute pain exacerbation.1 In a retrospective cohort study of 8,443 workers’ compensation claims for acute disabling lower back pain, looking at claims from January 1, 2002, and December 31, 2003, intensive use of opioids early in treatment was associated with worse long-term outcomes, increased use of costly medical services (including surgery), prolonged disability, and continued use of opioids.1 One dilemma that arises with using opioids long term is that hyperalgesia (increased pain sensitivity), decreased libido and other hormonal effects, and depression may occur, as well as tolerance. Statistics have shown that at least 1 of these effects is experienced by 51% of all patients taking oral opioids.2 Another concern is the risk of dependence and addiction. For most of the twentieth century, opioid dependence has been problematic.11 A review of 24 studies (2,507 chronic pain patients) have shown that there is a 3.3% risk of developing addiction.6 While this percentage is low, it represents a large population that is hard to manage. Evaluating and re-evaluating patients who are at higher risk of developing addiction is something that all clinicians treating chronic pain patients treated with opioids should be performing on an ongoing basis.6