Prevention of Opioid Misuse: A Summary with Suggestions from a Pain Working Group.

Abstract

On November 6, 2014, a multidisciplinary group of experts and stakeholders attended a Prevention of Opioid Misuse Study Day in Toronto funded by the Canadian Institutes of Health Research (CIHR) under a Canada Research Initiative in Substance Misuse (CRISM, grant number CSM-133338). The goals were to clarify issues surrounding opioid medications, including a discussion of current facts and myths, produce a summary of evidence based information to guide health professionals on the best practices in managing acute and chronic pain, inform clinicians, government, and other stakeholders about opioid use/misuse and pain management issues. Specific Principles That Guided the Summary. The following are the specific principles that guided the summary: We recognize the rise in morbidity and mortality associated with opioid misuse and the risk of addiction. We recognize the importance of the International Association for Study of Pain, Montreal, 2010 declaration on the right of person with pain to get relief: http://www.iasp-pain.org/DeclarationofMontreal. We recognize that available alternatives to opioids should be used in first intention (e.g., nonsteroidal analgesics, pregabalin, mood related medication such as duloxetine, and physical and behavioral approaches). We endorse the 2010 Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain: http://nationalpaincentre.mcmaster.ca/opioid/. These are solid and remain valid. We also deplore the low access to pain experts and other management options in Canada (mainly in rural areas or low income urban ones) and the absence of newer medications with high effectiveness and low harm. 2. Review of Current Issues on Pain and Its Relief One in five Canadians suffers from chronic pain [1, 2]. Many people living with chronic pain are “invisible” sufferers. Their quality of life is seriously compromised, and if their pain is not managed they are at greater risk of additional problems. Importantly, an association between opioid medication misuse and mood problems including depression and anxiety has been reported [3]. Furthermore, in the absence of adequate pain relief, the risk for suicide increases [4, 5]. Unfortunately, there are no magic cures for chronic pain. When all other alternatives have failed to provide acceptable control of pain, opioid analgesics (e.g., morphine, oxycodone, hydromorphone, and fentanyl) are increasingly being prescribed to relieve pain and improve the quality of life for people living with chronic pain so they can continue working and carrying out routine daily tasks. However, opioids if used inappropriately come with definite serious risks: addiction, fatal overdose, and harmful or even deadly effects when combined with other drugs or substances (particularly alcohol and antianxiety medications). The prevention of opioid misuse requires careful screening by educated prescribers, increased safety education to patients and population, and increased access to addiction and mental health services across all age groups and regions in Canada with a special attention to access to pain management and its prevention in nonurban sites [6]. It is important to distinguish between abuse, addiction, and physical dependence (see page 124 of the Canadian Guidelines: http://nationalpaincentre.mcmaster.ca/documents/opioid_guideline_part_b_v5_6.pdf): Abuse is any use of an illegal drug or the intentional self-administration of a medication for a nonmedical purpose such as altering one's state of consciousness, for example, “getting high.” Addiction is a primary, chronic, neurobiological disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving. Misuse of opioid is use of an opioid in ways other than those intended by a prescribing health professional. Physical dependence is a state of adaptation manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug, and/or administration of an antagonist. The nonmedical use of any prescription medication, including opioids, is a major concern. All medications have adverse effects, but if opioids are inappropriately used they are potentially life-threatening due primarily to sedation and respiratory depression. It is important to address this problem and to implement appropriate solutions. The national Canadian Alcohol and Drug Use Monitoring Survey (CADUMS) of the general population aged 15 years and older included nonmedical users who acknowledged using pain relievers more than they were supposed to or without a prescription. Starting in 2009, CADUMS has also asked respondents if they had used the medication “to get high.” The findings indicated that the prevalence of any use of a prescription opioid analgesic (POA) in Canada had decreased from roughly 20% to 17%, with use without a prescription at about 4.8–5% and use to get high at about 0.3%.