Opioid Misuse and Abuse: Risk Assessment and Management in Patients with Cancer Pain

View More View Less
  • a From the Division of Anesthesia and Pain Management Service and Department of Psychology, St. Jude Children’s Research Hospital, Memphis, Tennessee.

The FDA’s 2012 risk evaluation and mitigation strategy is a major step toward systematically reducing the inherent risks of chronic opioid therapy for pain, but does not distinguish between risks related to sources of pain. This article discusses the effect of risk mitigation in the treatment of cancer pain, with a focus on pretreatment screening and ongoing monitoring in this patient population that often requires pain management at some time during cancer treatment. Experience with screening, risk stratification, and interventions at one cancer center is shared, along with some recommendations for practice. A new screening checklist is proposed that summarizes known risk factors. Patients with cancer are not protected from the problems of opioid abuse/misuse, and the multidisciplinary cancer treatment team should coordinate an evaluation of risk and the monitoring of aberrant behaviors as part of the comprehensive care plan.

Correspondence: Doralina L. Anghelescu, MD, Division of Anesthesia, Mail Stop 130, St. Jude Children’s Research Hospital, 262 Danny Thomas Place, Memphis, TN 38105-2794. E-mail: doralina.anghelescu@stjude.org
  • 1.

    Swarm RA, Abernethy AP, Anghelescu DL et al.. NCCN Clinical Practice Guidelines in Oncology: Adult Cancer Pain. Version 1, 2013. Available at: NCCN.org. Accessed March 4, 2013.

    • Search Google Scholar
    • Export Citation
  • 2.

    US Food and Drug Administration. Extended-release (ER) and long-acting (LA) opioid analgesics risk evaluation and mitication strategy (REMS), version 8/2012. Accessed March 4, 2013. Available at: http://www.fda.gov/downloads/Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/UCM311290.pdf.

    • Search Google Scholar
    • Export Citation
  • 3.

    Colliver JD, Kopstein AN. Trends in cocaine abuse reflected in emergency room episodes reported to DAWN. Drug Abuse Warning Network. Public Health Rep 1991;106:5968.

    • Search Google Scholar
    • Export Citation
  • 4.

    Gfroerer J, Brodsky M. The incidence of illicit drug use in the United States, 1962-1989. Br J Addict 1992;87:13451351.

  • 5.

    Regier DA, Myers JK, Kramer M et al.. The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry 1984;41:934941.

    • Search Google Scholar
    • Export Citation
  • 6.

    Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 1: prevalence and diagnosis. Oncology 1998;12:517-521, 524.

    • Search Google Scholar
    • Export Citation
  • 7.

    Derogatis LR, Morrow GR, Fetting J et al.. The prevalence of psychiatric disorders among cancer patients. JAMA 1983;249:751757.

  • 8.

    Starr TD, Rogak LJ, Passik SD. Substance abuse in cancer pain. Curr Pain Headache Rep 2010;14:268275.

  • 9.

    Ives TJ, Chelminski PR, Hammett-Stabler CA et al.. Predictors of opioid misuse in patients with chronic pain: a prospective cohort study. BMC Health Serv Res 2006;6:46.

    • Search Google Scholar
    • Export Citation
  • 10.

    Pergolizzi JV Jr, Gharibo C, Passik S et al.. Dynamic risk factors in the misuse of opioid analgesics. J Psychosom Res 2012;72:443451.

  • 11.

    Manchikanti L, Manchukonda R, Pampati V et al.. Does random urine drug testing reduce illicit drug use in chronic pain patients receiving opioids? Pain Physician 2006;9:123129.

    • Search Google Scholar
    • Export Citation
  • 12.

    Passik SD, Messina J, Golsorkhi A et al.. Aberrant drug-related behavior observed during clinical studies involving patients taking chronic opioid therapy for persistent pain and fentanyl buccal tablet for breakthrough pain. J Pain Symptom Manage 2011;41:116125.

    • Search Google Scholar
    • Export Citation
  • 13.

    Papaleontiou M, Henderson CR Jr, Turner BJ et al.. Outcomes associated with opioid use in the treatment of chronic noncancer pain in older adults: a systematic review and meta-analysis. J Am Geriatr Soc 2010;58:13531369.

    • Search Google Scholar
    • Export Citation
  • 14.

    Edlund MJ, Sullivan M, Steffick D et al.. Do users of regularly prescribed opioids have higher rates of substance use problems than nonusers? Pain Med 2007;8:647656.

    • Search Google Scholar
    • Export Citation
  • 15.

    Jamison RN, Kauffman J, Katz NP. Characteristics of methadone maintenance patients with chronic pain. J Pain Symptom Manage 2000;19:5362.

  • 16.

    Passik SD. Issues in long-term opioid therapy: unmet needs, risks, and solutions. Mayo Clin Proc 2009;84:593601.

  • 17.

    Portenoy RK, Lesage P. Management of cancer pain. Lancet 1999;353:16951700.

  • 18.

    Gudin J. Risk Evaluation and Mitigation Strategies (REMS) for extended-release and long-acting opioid analgesics: considerations for palliative care practice. J Pain Palliat Care Pharmacother 2012;26:136143.

    • Search Google Scholar
    • Export Citation
  • 19.

    Webster LR, Fine PG. Approaches to improve pain relief while minimizing opioid abuse liability. J Pain 2010;11:602611.

  • 20.

    Jamison RN, Ross EL, Michna E et al.. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: a randomized trial. Pain 2010;150:390400.

    • Search Google Scholar
    • Export Citation
  • 21.

    Sehgal N, Manchikanti L, Smith HS. Prescription opioid abuse in chronic pain: a review of opioid abuse predictors and strategies to curb opioid abuse. Pain Physician 2012;15:ES6792.

    • Search Google Scholar
    • Export Citation
  • 22.

    Turk DC, Swanson KS, Gatchel RJ. Predicting opioid misuse by chronic pain patients: a systematic review and literature synthesis. Clin J Pain 2008;24:497508.

    • Search Google Scholar
    • Export Citation
  • 23.

    Wang J, Christo PJ. The influence of prescription monitoring programs on chronic pain management. Pain Physician 2009;12:507515.

  • 24.

    Tennessee Department of Health. Frequently asked questions: controlled substance monitoring database (CSMD) and prescription safety act. Available at: https://health.state.tn.us/boards/Controlledsubstance/faq.shtml. Accessed March 6, 2013.

    • Search Google Scholar
    • Export Citation
  • 25.

    Moore TM, Jones T, Browder JH et al.. A comparison of common screening methods for predicting aberrant drug-related behavior among patients receiving opioids for chronic pain management. Pain Med 2009;10:14261433.

    • Search Google Scholar
    • Export Citation
  • 26.

    Nakawaki B, Crano WD. Predicting adolescents’ persistence, non-persistence, and recent onset of nonmedical use of opioids and stimulants. Addict Behav 2012;37:716721.

    • Search Google Scholar
    • Export Citation
  • 27.

    Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med 2005;6:432442.

    • Search Google Scholar
    • Export Citation
  • 28.

    Grattan A, Sullivan MD, Saunders KW et al.. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med 2012;10:304311.

    • Search Google Scholar
    • Export Citation
  • 29.

    Wasan AD, Butler SF, Budman SH et al.. Psychiatric history and psychologic adjustment as risk factors for aberrant drug-related behavior among patients with chronic pain. Clin J Pain 2007;23:307315.

    • Search Google Scholar
    • Export Citation
  • 30.

    Boyd CJ, Young A, Grey M et al.. Adolescents’ nonmedical use of prescription medications and other problem behaviors. J Adolesc Health 2009;45:543550.

    • Search Google Scholar
    • Export Citation
  • 31.

    McCabe SE, West BT, Teter CJ et al.. Co-ingestion of prescription opioids and other drugs among high school seniors: results from a national study. Drug Alcohol Depend 2012;126:6570.

    • Search Google Scholar
    • Export Citation
  • 32.

    Michna E, Ross EL, Hynes WL et al.. Predicting aberrant drug behavior in patients treated for chronic pain: importance of abuse history. J Pain Symptom Manage 2004;28:250258.

    • Search Google Scholar
    • Export Citation
  • 33.

    Lord S, Downs G, Furtaw P et al.. Nonmedical use of prescription opioids and stimulants among student pharmacists. J Am Pharm Assoc (2003) 2009;49:519528.

    • Search Google Scholar
    • Export Citation
  • 34.

    Castellanos-Ryan N, O’Leary-Barrett M, Sully L et al.. Sensitivity and specificity of a brief personality screening instrument in predicting future substance use, emotional, and behavioral problems: 18-month predictive validity of the substance use risk profile scale. Alcohol Clin Exp Res 2013;37(Suppl 1):E281290.

    • Search Google Scholar
    • Export Citation
  • 35.

    Solanki DR, Koyyalagunta D, Shah RV et al.. Monitoring opioid adherence in chronic pain patients: assessment of risk of substance misuse. Pain Physician 2011;14:E119131.

    • Search Google Scholar
    • Export Citation
  • 36.

    Koyyalagunta D, Burton AW, Toro MP et al.. Opioid abuse in cancer pain: report of two cases and presentation of an algorithm of multidisciplinary care. Pain Physician 2011;14:E361371.

    • Search Google Scholar
    • Export Citation
  • 37.

    Butler SF, Fernandez K, Benoit C et al.. Validation of the revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R). J Pain 2008;9:360372.

    • Search Google Scholar
    • Export Citation
  • 38.

    Butler SF, Budman SH, Fernandez KC et al.. Cross-validation of a screener to predict opioid misuse in chronic pain patients (SOAPP-R). J Addict Med 2009;3:6673.

    • Search Google Scholar
    • Export Citation
  • 39.

    Edwards RR, Wasan AD, Michna E et al.. Elevated pain sensitivity in chronic pain patients at risk for opioid misuse. J Pain 2011;12:953963.

  • 40.

    Jones T, Moore T, Levy JL et al.. A comparison of various risk screening methods in predicting discharge from opioid treatment. Clin J Pain 2012;28:93100.

    • Search Google Scholar
    • Export Citation
  • 41.

    Gourlay DL, Heit HA, Almahrezi A. Universal precautions in pain medicine: a rational approach to the treatment of chronic pain. Pain Med 2005;6:107112.

    • Search Google Scholar
    • Export Citation
  • 42.

    Lock it up: medicine safety in your home. US Food and Drug Administration Web site. Available at: http://www.fda.gov/ForConsumers/ConsumerUpdates/ucm272905.htm. Accessed March 8, 2013.

    • Search Google Scholar
    • Export Citation
  • 43.

    FDA consumer health information. How to dispose of unused medicines. US Food and Drug Administration Web site. Available at: http://www.fda.gov/downloads/Drugs/ResourcesForYou/Consumers/BuyingUsingMedicineSafely/UnderstandingOver-the-CounterMedicines/ucm107163.pdf. Accessed March 8, 2013 .

    • Search Google Scholar
    • Export Citation
  • 44.

    Starrels JL, Becker WC, Alford DP et al.. Systematic review: treatment agreements and urine drug testing to reduce opioid misuse in patients with chronic pain. Ann Intern Med 2010;152:712720.

    • Search Google Scholar
    • Export Citation
  • 45.

    Payne R, Anderson E, Arnold R et al.. A rose by any other name: pain contracts/agreements. Am J Bioeth 2010;10:512.

  • 46.

    Miaskowski C, Dodd MJ, West C et al.. Lack of adherence with the analgesic regimen: a significant barrier to effective cancer pain management. J Clin Oncol 2001;19:42754279.

    • Search Google Scholar
    • Export Citation
  • 47.

    Owen GT, Burton AW, Schade CM et al.. Urine drug testing: current recommendations and best practices. Pain Physician 2012;15:ES119133.

  • 48.

    Cone EJ, Caplan YH, Black DL et al.. Urine drug testing of chronic pain patients: licit and illicit drug patterns. J Anal Toxicol 2008;32:530543.

  • 49.

    Fishman SM, Wilsey B, Yang J et al.. Adherence monitoring and drug surveillance in chronic opioid therapy. J Pain Symptom Manage 2000;20:293307.

  • 50.

    Christo PJ, Manchikanti L, Ruan X et al.. Urine drug testing in chronic pain. Pain Physician 2011;14:123143.

  • 51.

    Butler SF, Budman SH, Fanciullo GJ et al.. Cross validation of the Current Opioid Misuse Measure to monitor chronic pain patients on opioid therapy. Clin J Pain 2010;26:770776.

    • Search Google Scholar
    • Export Citation
  • 52.

    Butler SF, Budman SH, Fernandez KC et al.. Development and validation of the Current Opioid Misuse Measure. Pain 2007;130:144156.

  • 53.

    Wu SM, Compton P, Bolus R et al.. The addiction behaviors checklist: validation of a new clinician-based measure of inappropriate opioid use in chronic pain. J Pain Symptom Manage 2006;32:342351.

    • Search Google Scholar
    • Export Citation
  • 54.

    Breitbart W, Rosenfeld B, Passik S et al.. A comparison of pain report and adequacy of analgesic therapy in ambulatory AIDS patients with and without a history of substance abuse. Pain 1997;72:235243.

    • Search Google Scholar
    • Export Citation
  • 55.

    Portenoy RK. Opioid therapy for chronic nonmalignant pain: a review of the critical issues. J Pain Symptom Manage 1996;11:203217.

  • 56.

    Weaver MF, Schnoll SH. Opioid treatment of chronic pain in patients with addiction. J Pain Palliat Care Pharmacother 2002;16:526.

  • 57.

    Ziegler PP. Addiction and the treatment of pain. Subst Use Misuse 2005;40:1945-1954, 2043-1948.

  • 58.

    Passik SD, Kirsh KL, Donaghy KB et al.. Pain and aberrant drug-related behaviors in medically ill patients with and without histories of substance abuse. Clin J Pain 2006;22:173181.

    • Search Google Scholar
    • Export Citation
  • 59.

    Martin WR, Jasinski DR. Physiological parameters of morphine dependence in man—tolerance, early abstinence, protracted abstinence. J Psychiatr Res 1969;7:917.

    • Search Google Scholar
    • Export Citation
  • 60.

    Dole VP. Narcotic addiction, physical dependence and relapse. N Engl J Med 1972;286:988992.

  • 61.

    Redmond DE Jr, Krystal JH. Multiple mechanisms of withdrawal from opioid drugs. Annu Rev Neurosci 1984;7:443478.

  • 62.

    Rinaldi RC, Steindler EM, Wilford BB et al.. Clarification and standardization of substance abuse terminology. JAMA 1988;259:555557.

  • 63.

    Weissman DE, Haddox JD. Opioid pseudoaddiction—an iatrogenic syndrome. Pain 1989;36:363366.

  • 64.

    Holmes CP, Gatchel RJ, Adams LL et al.. An opioid screening instrument: long-term evaluation of the utility of the Pain Medication Questionnaire. Pain Pract 2006;6:7488.

    • Search Google Scholar
    • Export Citation
  • 65.

    Compton P, Darakjian J, Miotto K. Screening for addiction in patients with chronic pain and “problematic” substance use: evaluation of a pilot assessment tool. J Pain Symptom Manage 1998;16:355363.

    • Search Google Scholar
    • Export Citation
  • 66.

    Compton PA, Wu SM, Schieffer B et al.. Introduction of a self-report version of the Prescription Drug Use Questionnaire and relationship to medication agreement noncompliance. J Pain Symptom Manage 2008;36:383395.

    • Search Google Scholar
    • Export Citation
  • 67.

    Ahmed AG, Salib E, Ruben S. Psychiatric disorders in first-degree relatives of patients with opiate dependence. Med Sci Law 1999;39:219227.

All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 1872 381 24
PDF Downloads 723 269 19
EPUB Downloads 0 0 0