J R Soc Med 2004;97:62-65
doi:10.1258/jrsm.97.2.62
© 2004 Royal Society of Medicine
Chronic non-cancer pain and opioid dependence
Christopher Littlejohn BSc RMN
Alex Baldacchino MPhil MRCPych
Jonathan Bannister MB FRCA 1
Centre for Addiction Research and Education Scotland, Department of
Psychiatry, University of Dundee
1 Pain Clinic, Ninewells Hospital and Medical School, Dundee, Scotland, UK
Correspondence to: Dr Alex Baldacchino, Centre for Addiction Research and
Education Scotland, Department of Psychiatry, Ninewells Hospital and Medical
School, Dundee DD1 9SY, Scotland, UK E-mail:
a.baldacchino{at}sghms.ac.uk
 |
INTRODUCTION
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There are four main questions to address on the subject of chronic
non-cancer
pain and opioid addiction. Are opioids effective in the treatment
of
such pain? If so, do the risks of iatrogenic addiction outweigh
the
benefits? To what extent do patients with primary opioid
addiction experience
chronic pain? How should this pain be treated?
We review the subject from a UK perspective. Most of the published work
comes from the USA, where addiction tends to be viewed primarily as a
neurobiological disease or disorder, albeit one that can be influenced by
environmental
factors.1 UK workers
are less inclined to privilege the biological over the
psychosocial—readier to accept that people can make heavy use of drugs
without being addicted, that the heavy use of drugs can be a choice rather
than 'loss of control', and that many people can modify their drug
consumption without
help.2 Indeed, there
are those who see addicts' descriptions of their 'compulsive
behaviours' as an artifact of the social and legal prohibitions on the
use of drugs (i.e. that the claim 'I only take drugs because I am
addicted' is merely a post-hoc
rationalization).3
Even in the treatment of pain, the prescription of opioid analgesics has waxed
and waned according to the fashion of the moment.
The term addiction is ubiquitous in the published work but is no longer
found in either of the contemporary diagnostic manuals, the Diagnostic and
Statistical Manual of Mental Disorders
(DSM)4 or the
International Classification of Diseases
(ICD).5 We use it
here because it retains ideas about 'loss of control' and chaotic
drug use despite adverse physical, mental and social consequences.
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METHOD
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To address the four questions we searched CINAHL, Embase, MEDLINE
and
PsycINFO with the terms 'chronic pain', 'addiction',
'drug
abuse', 'opioid dependence', and 'substance
dependence'. The
search was confined to papers published in the past ten
years:
we decided that older papers that had 'stood the test of
time'
would continue to be cited. A total of 555 records were retrieved,
of
which 266 were selected by scrutiny of abstracts. We excluded
papers that
were not in English, that did not deal with human
addiction, that addressed
chronic cancer-related pain, and that
were unrelated to opioid use disorders.
We found 102 relevant
papers, including those identified from a citation
search. These
comprised 34 primary papers (i.e. empirical research reports)
and
68 secondary papers (reviews and opinions). Most of them originated
from
the USA (67, compared with the UK contribution, in second
place, of 12). The
largest body of work—24 primary papers,
all the secondary
papers—addressed the treatment of chronic
pain with opioids. The
remaining 10 dealt with chronic pain
in patients being treated for a primary
opioid addiction.
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ARE OPIOIDS EFFECTIVE IN THE TREATMENT OF CHRONIC PAIN?
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Although opioid analgesics are now widely used for pain and
in palliative
care,
6 this was not
always so. Even in acute pain,
several studies were required to dispel the
myth that a single
dose could create
addiction.
7-9
That opioids can be effective
in chronic pain is not in
doubt:
10-12
for example, placebo controlled
studies have demonstrated the value of
codeine,
13 and of
morphine
in chronic pain unrelieved by other
treatment.
14 Even
neuropathic
pain, which is often
opioid-resistant,
15
is not consistently
unresponsive;
16
comment
on this matter is made difficult by a shortage of rigorous
research.
17
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IF OPIOIDS ARE EFFECTIVE, DO THE RISKS OF IATROGENIC ADDICTION OUTWEIGH THE BENEFITS?
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Discussion of the addictive potential of opioids features mainly
in reviews
and expert guidance for clinicians on the careful
use of opioids in chronic
pain.
18-21
Some argue that patients
at high risk of iatrogenic addiction can be
identified and
excluded;
16,22
others
declare that the risks of iatrogenic addiction have been exaggerated
to
the extent that no patient with chronic pain should be deprived
of effective
treatment.
23-25
Expert opinion currently leans
to the view that, in chronic pain, opioid
treatment does not
carry a high risk of iatrogenic
addiction.
26-28
Can the risk be quantified? This is a concern for patients as well as
clinicians. In a 1994 survey of chronic pain patients taking long-term
opioids, nearly two-thirds expressed anxiety that they might become addicted,
though the same proportion had not had to increase their consumption of the
drugs. Prevalence studies have done little to clarify matters. Some have been
essentially negative. For example, Moulin and
Iezzi14 found no
instances of addiction in their 22-week study of oral morphine; and
Dellemijn11 saw no
withdrawal effects or addictive behaviour in 5 patients treated for up to two
years with transdermal fentanyl.
The study by Hoffman and
colleagues,29 using
DSM-III-R criteria in chronic-pain patients, gave more cause for concern,
finding 'analgesic misuse' in 1.9% and 'analgesic
dependence' in 12.6%. This was to be compared with a prevalence rate of
addiction in the general population of between 3% and
26%.30 Kouyanou and
colleagues,31 in
the UK, likewise used DSM-III-R criteria in chronic-pain patients and found
opioid abuse in 3.2%, opioid dependence in 4.8%. Other groups have reported
much higher rates of substance abuse in such patients: Maruta et
al.,32 in the
pre-DSM-III era, 24% drug dependence, 41% drug abuse; Reid et
al.33
prescription opioid abuse by 24-31%; Bouckoms et
al.10 24%
'serious narcotic abuse', 27% 'narcotic addiction'.
However, any attempt to measure prevalence is wholly dependent on the
definitions. For example, in one study the prevalence of 'analgesic
substance use disorder' was 22% with DSM-III criteria, 18% with DSM-IV
criteria.34
There is reason to question the validity of criteria for substance abuse
disorders. In their retrospective study of opioid therapy for chronic pain,
Dunbar and Katz identified 20 patients with a previous history of substance
misuse.35 They
divided these patients into two groups according to whether the treating
physician suspected them of being addicted to their prescribed opioids. Those
who were judged to show addictive behaviour, such as unauthorized dose
escalations or 'doctor shopping', were noted to have significantly
more unrelieved pain than the non-addicted group. This raised the possibility
that what appears to be addiction in some chronic pain patients is the same as
the 'pseudo-addiction' reported in patients with cancer whose pain
is unrelieved, and whose addictive behaviours disappear once pain relief is
achieved.36 When we
consider the diagnostic criteria for substance dependence as they appear in
both DSM-IV and ICD-10, their inadequacies in this group become obvious.
First, in long-term opioid treatment, one or both of the physiological
criteria (tolerance and withdrawal) are likely to develop, but in the context
of pain management are not to be regarded as pathological (it is noteworthy
that many illicit addicts do not demonstrate these physiological
changes30). Second,
the behavioural criteria (e.g. increasing importance of acquiring and using
the drug, compulsion to use, impaired control, reduced social or recreational
activities) can be a manifestation, in the chronic-pain patient, of
therapeutic dependence—attempts to secure supplies of analgesia in the
face of fear and anxiety about running out of analgesics, or of worsening or
breakthrough
pain.37 Chronic
pain by its nature reduces peoples' desire and ability to socialize or
remain active, and is a major risk factor for depression. Furthermore, for
those whose pain is unrelieved, the desperate visits to multiple practitioners
(seeking one who will take their pain seriously), the quest for analgesic
drugs, can give a false impression of addiction.
These shortcomings have been recognized by some groups, and there have been
attempts in the US to create diagnostic criteria for identifying pathological
addiction in the context of opioid treatment for chronic pain. However,
provisional testing of the new criteria has still found that one in five
'non-addicted' patients will demonstrate the very behaviours taken
to be diagnostic of
addiction.37
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DO THOSE WITH A PRIMARY OPIOID USE DISORDER EXPERIENCE CHRONIC PAIN, AND IF SO HOW SHOULD PAIN BE TREATED?
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Practitioners tend to be cautious when patients report pain,
knowing that
some exaggerate or lie so as to obtain opioids
for the drugs'
psychoactive
properties.
38
Meanwhile, practitioners
who 'over-prescribe' have been condemned as
'dated, duped, dishonest
or disabled'—out-of-date with
contemporary practice; duped
by manipulative patients; dishonest in providing
illicit prescriptions
for material gain; or disabled, in being themselves
affected
by a chemical dependency or personality disorder that distorts
their
prescribing
practices.
39 Yet
patients with primary opioid
dependence do report high levels of chronic pain,
even when
intuition would suggest that they should experience less (for
example,
those receiving methadone maintenance in high daily
doses).
40 Although
methadone has been found effective in management of
comorbid opioid dependence
and chronic pain,
41
between 24% and
61% of individuals on methadone maintenance report chronic
pain.
42,43
There
is much experimental evidence that those receiving methadone
maintenance
have
lower pain thresholds than controls (i.e. that
they feel pain
more easily).
44
There is good reason therefore to consider the opioid-dependent population
as being likely to experience chronic pain. It seems doubtful that the simple
exposure to opioid medicines, when they are used to treat chronic pain, risks
making a current addiction worse or rekindling an addiction that has been
previously overcome. Even those with a history of substance use disorders can
have their chronic pain effectively treated with
opioids.45 The
primary task would seem to be to increase our ability to identify patients who
falsely seek opioid drugs in the absence of pain. These patients' complex
problems require the integration of expertise from specialists in pain and
addiction management.
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CONCLUSION
|
|---|
The published work on comorbid chronic pain and addiction is
dominated by
opinion rather than evidence. We suspect that,
as happened previously with
acute pain and palliative care,
fears about addiction from opioid therapy in
chronic non-cancer
pain have been excessive. This is not to argue that opioids
are
always the drug of choice for chronic pain—just that excluding
them
a priori appears based more upon ignorance than on science.
Of
course, opioids are not 'ordinary' medicines, subject as
they are to
serious cultural and legal sanctions for unprescribed
use. Yet perhaps the
opioids' special legal status adds to the
need to separate their
'proper' medicinal (analgesic) properties
from their prohibited
psychoactive properties. (Are we sure
that opioid-induced euphoria is a
'bad thing' in those whose
lives are blighted by unremitting pain?)
What is problematic
is the insensitivity of our current tools for telling us
when
patients are running into difficulties with their prescribed
opioids.
They do not allow us to differentiate between the drug-seeking
opioid
'addict' and the patient who is desperate because of
unrelieved
pain. We cannot objectively tell the addicted from
the pseudo-addicted.
Probably the tools for such differentiation
should be developed locally rather
than imported from the USA,
where the concepts differ.
The finding of high pain levels in the context of maintenance opioid
treatment of addiction merits further research. Does long-term administration
of opioids modify pain perception, or do those who develop primary opioid
addiction inherently differ in their perception or experience of pain? It
would be wise to temper scepticism when such individuals complain of pain.
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INTRODUCTION
METHOD
