| 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 Noncancer
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.
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