Review of addiction to prescription painkillers

Chemical dependency and recovery in patients and physicians are closely examined in a series of articles and editorials in the July 2009 issue of Mayo Clinic Proceedings. The subject is especially timely. As the immense challenges, including potential tragedies, of prescription chemical addiction and abuse are being discussed, these articles offer crucial overview, direction and optimism.

Addiction to and abuse of prescription opioid drugs are prevalent, and they exact an immense toll on patients, physicians and society, according to Steven Passik, Ph.D., Department of Psychiatry and Behavioral Sciences, Memorial Sloan-Kettering Cancer Center, New York, in "Issues in Long-Term Opioid Therapy: Unmet Needs, Risks, and Solutions."

Opioid drugs have been used by humans for thousands of years and are the longest continuously used class of medications, explains William Lanier, M.D., editor-in-chief of Mayo Clinic Proceedings. Dr. Lanier and Evan Kharasch, M.D., Ph.D., Department of Anesthesiology, Washington University in St. Louis, authored the editorial "Contemporary Clinical Opioid Use: Opportunities and Challenges." It summarizes the recent increased interest in this drug category.

Opioid medications are chemicals that work by binding to specific receptors, particularly in the nervous system and gastrointestinal tract; decrease perception of pain and reaction to pain; and increase pain tolerance. Side effects include sedation, respiratory depression and constipation. When opioid consumption is ongoing, physical dependence can and will develop. This, in turn, can lead to problematic withdrawal upon abrupt discontinuation of medication. Dependence, coupled with the feeling of euphoria these drugs can produce, leads to abuse.

According to Dr. Lanier, the recent growing interest in opioids stems from five sources: advances in the design of these drugs; expansion and innovation in methods of drug delivery; increased public awareness of pain management options and the appropriateness of aggressively treating pain as the "fifth vital sign" and pain relief as a fundamental human right; growing recognition of the serious consequences of opioid misuse, misadventure and addiction; and medicolegal aspects of practitioners' prescribing practices and legal consequences for under- or overprescribing.

In addition to individuals who have chronic pain, both cancer and non-cancer related, anesthesiologists have the greatest risk of opioid dependence and abuse among health care providers. Also in the high-risk group for health care providers are nurse anesthetists and sedation nurses. Challenges specific to these groups are discussed by Michael Oreskovich, M.D., Washington Physicians Health Program in Seattle, and Ryan Caldeiro, M.D., Department of Psychiatry and Behavioral Sciences at the University of Washington, Seattle, in "Anesthesiologists Recovering From Chemical Dependency: Can They Safely Return to the Operating Room?"

Severe chronic pain includes that produced by cancer and such non-cancer conditions as back injury and surgery. Opioids are a cornerstone of pain management for individuals in these categories, according to Howard Smith, M.D., Department of Anesthesiology, Albany Medical College, N.Y. In "Opioid Metabolism," he writes that approximately 10 percent to 20 percent of physicians will develop a substance abuse problem during their career, a rate similar to or exceeding the general population. For anesthesiologists, according to Drs. Oreskovich and Caldeiro, the increased risk is cited as an occupational hazard because of the highly addictive medications they administer to patients daily.

Health care professionals helping patients with chronic pain must balance aggressive treatment with the need to minimize the risks of misuse and abuse, according to Dr. Passik. In "A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Non-cancer Pain," Charles Argoff, M.D., and Daniel Silvershein, M.D., both from the Department of Neurology, Albany Medical College, N.Y., write that management of chronic non-cancer pain, for example, requires comprehensive assessment of each patient; the establishment of a structured treatment regimen or program; ongoing reassessment of the pain condition and the response to therapy; and a continual appraisal of the patient's adherence to the treatment. Their colleague, Dr. Smith, stresses the importance of understanding the metabolism of opioids in individual patients.

Keen awareness by family and friends of potential addiction is crucial for physicians and other health care providers, not to mention the general public, who might be at risk, according to "Chemical Dependency and the Physician" by Keith Berge, M.D., Department of Anesthesiology, Mayo Clinic; Marvin Seppala, M.D., Hazelden Foundation, Center City, Minn.; and Agnes Schipper, J.D., Mayo Clinic Legal Department. Especially important is that family, friends and co-workers of health care providers confront any suspected addiction and abuse because of the potential harm that might befall the individual and his or her patients. Health care facilities should have written policies and procedures in place to assist when these highly emotionally charged situations involving health care providers occur, Dr. Berge and his colleagues write. Long-term recovery and sobriety can be achieved with appropriate treatment, aftercare and monitoring, they add.

New opioid formulas designed to minimize abuse are now in late-stage development and could help, Dr. Passik says. These drugs are chemically designed to diminish euphoric effects, thus possibly reducing problematic use. For now, responsibility coupled with expertise, insight, diligence and compassion are among the components that can meet the challenges of opioid use in pain management, the authors agree.

A peer-review journal, Mayo Clinic Proceedings publishes original articles and reviews dealing with clinical and laboratory medicine, clinical research, basic science research and clinical epidemiology. Mayo Clinic Proceedings is published monthly by Mayo Foundation for Medical Education and Research as part of its commitment to the medical education of physicians. The journal has been published for more than 80 years and has a circulation of 130,000 nationally and internationally. Articles are available online at www.mayoclinicproceedings.com.