How to avoid opioid misuse
These practical strategies will help you to identify and monitor the risk of opioid analgesic misuse.
Urine drug screens can identify substance abuse or dependence and potential problems you might not have detected.2 When used appropriately, urine drug screens can provide useful information about an individual’s substance abuse potential (such as a positive test for an illicit substance). The absence of a prescribed opioid may be as significant as a positive finding because this may suggest compliance issues or diversion.
Prescription monitoring programs have been established by most states since 2002 through grants from the Department of Justice. PMPs store prescription drug information from pharmacies in a statewide database and develop algorithms that can detect behaviors suggesting opioid misuse.18 For example, an algorithm may track factors such as having 5 or more prescribers, 3 or more pharmacies, or 3 or more early refills within 1 year.19
Individual states administer PMPs differently, but prescribers generally can request information to monitor individual patients and detect illicit behaviors. Although relatively new, PMPs have been shown to reduce prescription sales,20 doctor shopping,19 and opioid analgesic misuse.21 A comprehensive list of state PMPs is available from the Alliance of States with Prescription Monitoring Programs (www.pmpalliance.org/content/pmp-access).
| Key Point Although relatively new, prescription monitoring programs have been shown to reduce doctor shopping and opioid analgesic misuse. |
Responding to evidence of aberrant behavior
Even when you follow recommended opioid risk mitigation strategies, expect some individuals to show aberrant drug-taking behavior, abuse, or even the emergence of a co-occurring substance use disorder. Although evidence is limited regarding best practices in these circumstances, terminating opioid treatment is not necessarily the only option.8
Should you identify aberrant drug-related behaviors or any form of opioid analgesic misuse, evaluate the patient to determine the circumstances and immediately address the behavior. For example, using more medication than prescribed may be a sign of inadequately managed pain or clinical status, rather than an indication of abuse.
Referrals may be beneficial as part of your evaluation process. A pain specialist may offer alternative treatment approaches to mitigate medication overuse. An addiction specialist can evaluate patient safety for continued treatment with opioids, facilitate referrals for treatment of a substance use disorder, and provide consultation if discontinuing opioid therapy is appropriate.
Intervention. The patient’s pain complaint will persist whether or not you continue opioids, and substance abuse treatment may complement pain management. Even for an individual who continues opioid therapy, substance abuse treatment can provide tools for understanding and managing substance misuse. For instance, a cognitive-behavioral training program helped curb misuse and increase adherence in high-risk patients on opioid therapy for chronic back pain.22
Providing specialized care before you consider terminating opioid therapy allows people to address their reasons for misusing. Integrated treatment by a clinician specializing in co-occurring chronic pain and addiction may be particularly beneficial, as pain is an important motivator of individuals seeking treatment for an opioid use disorder.23
Termination. If, after additional resources and referral, an individual fails to make progress toward the therapeutic goal, you may need to terminate long-term opioid therapy. By making this decision, you may prevent the emergence of an opioid use disorder. Even so, telling someone that you are stopping opioid treatment can be a difficult discussion. The National Institute on Drug Abuse provides a wealth of online resources to assist with these and other opioid misuse conversations.24,25
Opioid detoxification is complex and should be managed and monitored to mitigate opioid withdrawal symptoms. Unfortunately, very little clinical guidance exists on effective opioid taper strategies for chronic pain patients. Consultation with an addiction specialist is recommended to assist with discontinuing treatment.
Future directions: A role for buprenorphine?
The introduction of transdermal buprenorphine in the United States in 2001 spurred new interest in this medication for treating moderate to severe chronic pain.26 Buprenorphine’s reported lower abuse potential may differentiate it from other opioid analgesics.27 Although a 2006 report showed evidence of modest diversion and abuse of buprenorphine,28 survey data and human laboratory studies demonstrate consistently that the abuse potential is lower—particularly with the combined buprenorphine/naloxone formulation—than with other opioids.29
Sublingual buprenorphine formulations, with and without naloxone, are FDA approved for opioid use disorder and opioid dependence, but not for pain. Thus, it is a medication with analgesic properties that is approved for an opioid use disorder. Some preliminary evidence supports off-label use of sublingual buprenorphine for chronic pain,30 but more research is needed before this approach can be recommended.
Additional clinical studies are examining whether the sublingual formulation’s efficacy for pain is comparable to other buprenorphine formulations. If this is supported, buprenorphine may become an appropriate, safer option for patients at risk of misusing who might benefit from continued opioid therapy.
