In recent years, clinicians have changed their attitudes regarding the use of opioids in light of the growing public health issue surrounding the potential of these drugs to be misused and abused. Risks associated with opioid use include overdose, drug dependence and subsequent withdrawal, addiction, and a negative impact on physical functioning.
“For many years, the United States went through a stretch when opioids were prescribed increasingly for pain relief,” explains Kevin E. Vowles, PhD. “Recent research, however, has indicated some potential problems associated with increases in opioid prescription rates. As a result, the prescribing of opioids is leveling off, but there is still a segment of the population that stands to benefit from using these medications.”
Experts have endorsed the notion that there is a need to differentiate and identify types of problems that may occur when using prescription opioids among patients with chronic pain. Some studies have attempted to calculate rates of problematic opioid use behavior, but these trials often suffer from imprecise and poorly defined terminology. “We’re lacking high-quality evidence on the identification of patients who are at risk for misusing and abusing opioids,” Dr. Vowles says.
An Updated Review
For a study published in Pain, Dr. Vowles and colleagues performed an updated review of problematic opioid use among patients with chronic pain. “Because previous reviews have indicated substantial variability in this literature,” says Dr. Vowles, “we took several steps to enhance precision and utility.”
The authors gathered data from 38 studies and explicitly coded the terms for rates of problematic opioid use in the available literature. They referred to different patterns of use, such as misuse, abuse, and addiction. The average prevalence rates were then calculated and weighted by sample size and study quality. The research team also examined the influence of differences in study methodology.
Overall, rates of problematic opioid use were broad, ranging from less than 1% to as high as 81% across studies. According to the research team, 76% of the studies examined in the analysis provided information on opioid misuse and 32% provided information on opioid addiction. Across most calculations, rates of opioid misuse ranged between 21% and 29%, whereas rates of opioid addiction were between 8% and 12%.
Just one of the 38 studies involved in the analysis reported data on the abuse of these drugs. When study methods were examined, the researchers observed that rates of addiction were lower in studies identifying prevalence assessments as a primary objective rather than a secondary one.
Dr. Vowles says his study team’s results are consistent with findings from previous research in many ways. “There continues to be substantial variability in studies evaluating problematic opioid use,” he says. “There were many different study designs, methods of identification, and settings that were used in the analyses examined in our review.” The range of rates of problematic use was broader than what has been previously reported in studies.
Based on the findings from Dr. Vowles and colleagues, misuse and addiction seem to be distinct patterns of problematic opioid use. It also appears that opioid misuse is more common than opioid addiction. Several types of misuse were identified, including:
- Erratic or disorganized use.
- Inappropriate use (eg, to manage symptoms other than pain).
- Use with alcohol or illegal substances.
“If it’s accurate that about one in four patients on opioids have patterns of misuse—but not addiction—then it may be more efficient to target safe treatment resources as interventions,” says Dr. Vowles. The study points out that some forms of misuse may be readily addressed with lower-intensity strategies, such as enhanced patient education or frequent follow-up visits.
The promotion of safer opioid use is paramount to curbing the epidemic of misuse, abuse, and addiction of these medications. The one-time rapid increase in opioid use had unintended consequences that—for some patients—means that more interventions will be needed to curtail problematic use and the potential for harm. “If opioids are here to stay, we must identify at-risk groups for addictive behaviors and tailor interventions to their needs,” Dr. Vowles says. “Simply not prescribing these medications at all will not cure the problem.” Pain treatment alternatives are available to healthcare providers who treat high-risk patients.
Dr. Vowles and colleagues provide several recommendations for future research on problematic opioid use in chronic pain (Table). “Overall, we need more studies with better trial designs,” says Dr. Vowles. “It has been established that opioids can help provide short-term pain relief, but their long-term efficacy must also be further investigated. Ultimately, this information may help clinicians better identify who is at risk and then develop targeted interventions to help reduce the opioid epidemic.”
Vowles KE, McEntee ML, Julnes PS, Frohe T, New JP, van der Goes DN. Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis. Pain. 2015;156:569-576. Available at: http://journals.lww.com/pain/Abstract/2015/04000/Rates_of_opioid_misuse,_abuse,_and_addiction_in.3.aspx.
Atluri S, Sudarshan G, Manchikanti L. Assessment of the trends in medical use and misuse of opioids analgesics from 2004 to 2011. Pain Physician. 2014;17:E119-E128.
Birnbaum HG, White AG, Schiller M, Waldman T, Cleveland JM, Roland CL. Societal costs of prescription opioid abuse, dependence, and misuse in the United States. Pain Med. 2011;12:657-667.
Brown J, Setnik B, Lee K, et al. Assessment, stratification, and monitoring of the risk for prescription opioid misuse and abuse in the primary care setting. J Opioid Manag. 2011;7:467-483.