The use of medication for acute or chronic pain for those with traumatic injuries can be an important element of treatment. Quality of life and functionality for chronic pain sufferers can be improved by the use of a variety of treatments, including medication.
The choice to treat pain with medication, however, can potentially lead to unintended consequences. One of the concerns presented by use of opioid analgesics is the potential for development of dependence or addiction.1 The issue has affected providers’ use of potentially addictive medicines over the last 30 years. Objective evidence regarding the incidence of addiction with the use of opioid medication on a long-term basis has been largely inconclusive.
A study published in June 2008 in the journal Pain Medicine2 attempts to quantify the risk of addiction and aberrant drug-related behaviors in long-term opioid use for chronic nonmalignant pain. The authors, led by David A. Fishbain, MD, performed a structured evidence-based review of all available studies on the development of abuse/addiction and aberrant drug-related behaviors (ADRBs) in chronic pain patients with chronic opioid analgesic therapy.
Of the 79 studies found, 12 were excluded based on exclusion criteria. The remaining 67 studies were sorted based upon reporting of development of abuse/addiction or ADBRs, or diagnosis of alcohol/illicit drug use as determined by urine toxicology.
One challenge of this review was a lack of standard definitions of abuse, addiction and aberrant drug-related behaviors. Only two of the studies reviewed utilized the correct concepts (psychological dependence and craving) for addiction. Aberrant drug-related behaviors (ADRBs) included a range of behaviors including aggressively requesting medication, unsanctioned dose escalation, or injecting medication.
The study found that the incidence of reported addiction in chronic pain patients exposed to chronic opioid analgesic therapy was only 3.27%, below the 10% addiction rate in the general population. However, physician-reported ADRBs were much greater (11.5%), but still within the range of the incidence in the general population. More concerning was the observation that urine toxicology identified a greater percentage of ADRBs (20.4%) than did physician observation alone (11.5%).
There was found to be a significant difference in the incidence of addiction and ADBRs when patients were preselected based upon history of drug or alcohol abuse or addiction. The incidence of addiction in patients with no history of abuse was only 0.19% compared to 3.27% for non-preselected patients. ADBRs were present in 0.59% of preselected patients versus 11.5% for non-preselected patients.
Preselection, therefore, is an important part of the decision to use opioid medication for chronic pain patients. Predictive variables for development of ADBRs found in the literature include:
- Previous history of alcohol/drug use
- Current history of alcohol/drug use
- Family history of alcohol/drug use
- Treatment in a drug rehabilitation center
- Use of multiple drugs
- Use of needles
- Smoking
If the results of the study are correct, the physician can be relatively certain that use of opioids for treatment of chronic pain will lead to addiction in a low percentage of patients. The incidence of addiction and ADBRs can be significantly reduced by careful preselection for patient and family history of drug and alcohol use. Since urine toxicology identifies a much larger percentage of illicit drug use than physician observation alone, the authors suggest routine use of ADBR lists and urine screening.
Use of opioid analgesic therapy has a place in the treatment of chronic pain. It reduces pain and permits improved function in daily activities. This study provides some reassurance that the incidence of addiction or aberrant behaviors may be low. At the same time, it indicates that the rate of improper drug usage detected by urine test is twice as large as the health care providers’ observations of their own patients. Careful preselection is important to avoid causing unintended consequences to chronic pain patients.
Also, we think that treatment options other than opiods should be used whenever possible, such as chiropractic, physical therapy, massage therapy or acupuncture. Placing a patient at risk of developing addiction issues superimposed upon chronic pain from trauma is a choice that health care providers should not have to face and those with traumatic injury should not have to endure. Finally, experienced counsel for those with traumatic injury can provide another set of ‘eyes and ears’ to ensure that addiction to pain medications or aberrant behaviors from its use are minimized. Counsel can also provide access to conservative treatment that has been hindered by insurance decisions and controls.
Treatment of chronic pain assumes the pain is caused by a nonmalignant source. The study discussed addresses only these types of patients. End-of-life treatment of pain presents different issues and is not addressed by the study examined here.
1 Fishbain, et al, Pain Med 2008 May-June; 9(4):444-59
