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The Three Worlds of Prescription Opioid Misuse

This article explores the iatrogenic epidemics and global problem of prescription opioid misuse, as well as the patterns of prescription and the different groups of people who misuse these drugs. It also discusses the management of pain in individuals with a history of addiction.

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The Three Worlds of Prescription Opioid Misuse

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  1. James Bell November 2014 The three worlds of prescription opioid misuse

  2. Dr Bell has received funding for research studies, travel to conferences, and hospitality, from ReckittBenckiser, Schering-Plough, Biomed P/L, Pfizer, Martindale, Titan Pharmaceuticals, and Munipharma

  3. Pain and Addiction 100 million adult Americans have chronic pain 2 million Americans dependent on prescribed opioids (cf ~500,000 heroin addicts) http://www.drugabuse.gov/news-events/nida-notes/2012/11/qa-dr-david-thomas

  4. Pain and Addiction “100 million adult Americans have chronic pain” 2 million Americans dependent on prescribed opioids (cf ~500,000 heroin addicts) Iatrogenic epidemics driven by unrealistic expectations

  5. Prescription opioids USA, 1995- 1999 - 2006 fatal poisonings (OD) involving prescription opioids more than tripled By 2004, prescription opioids surpassed heroin and cocaine in fatal ODs (Paulozzi and Xi 2008) And were increasingly a gateway to heroin addiction (Inciardi, 2009) As prescription of opioids for pain increases, non-medical use increases proportionally (Dasgupta, 2006)

  6. Global problem Similar trends to US identified in Australia, Canada, Europe and Asia

  7. Australian Opioid prescribing 1990s

  8. Opioid overdose presentations to ED, Australia (AIHW, 2008)

  9. An unprecedented epidemic of prescription opioid misuse 1995-2010?

  10. Opioid misuse 1860-1900 in USA ~1,000,000 opioid dependent people (1% of population) (Terry and Pellens, 1928) Most opioids were OTC (Heroin was marketed by Bayer, without prescription) Diversion was not a problem

  11. Medical practitioners 1860-1900 "The habit in a vast majority of cases is first formed by the unpardonable carelessness of physicians, who are fond of using the little syringe, or relieving every ache and pain by the administration of an opiate” Report toIowa Board of Health in 1885 (Quoted in Conrad and Schneider, 1992)

  12. Those who ignore history are condemned to repeat it • There is a latent demand for drugs which activate the reward pathway • Such drugs require different regulation – ethical codes, licensing, taxation, prohibition, guidelines • Medical profession has uneven record as gatekeepers for access to opioids

  13. Who misuses prescription opioids? 1. Some people prescribed opioids develop dependence, with escalating pain, distress and escalating doses of opioids 2. Current or former heroin addicts, some of whom use it as maintenance treatment, some who sell to the black market 3. Young people who use and share recreational drugs

  14. 1. Prescription opioid dependence Dependence on prescribed opioids and can contribute to pain, disability and distress Opioids contribute to pain through Reinforcing unrealistic expectations Withdrawal OIH (Opioid Induced Hyperalgesia)

  15. 2. DiversionDoctors prescribing patterns, USA 2009 Prescribing Patterns for All Prescribers Percentile10th 50th 90th US Mean Prescriptions per Beneficiary 6 1 3 16 Number of Pharmacies 32 1 17 85 Percentage of Schedule II Drugs 4% 0% 0% 10%

  16. Commercial traveller Patients US prescription data (McDonald, 2013) shows 0.7% of patients saw> 10 doctors and received 4% of all prescribed opioids French buprenorphine prescription data (Pradel, 2004) – 0.03% of patients obtained 45% of doctor-shopping medication. (Much of which was probably exported to Georgia)

  17. Aberrant behaviours (ADRBs) opioid diversion; taking doses larger than those prescribed continued requests for dose escalations; seeking opioids from different physicians; resisting urine drug screening or referral repeatedly losing medications or prescriptions seeking early refills; unscheduled visits misusing alcohol, using illicit drugs injecting (having track marks) or snorting meds obtaining medications from multiple doctors

  18. ADRBs in people prescribed opioids (Fishbain, 2008) 67 studies, pooled data Most ADRBs occur in people with addiction Hx (addiction Hx excluded studies 0.19%; other studies, 11.5% ADRBs) Urine testing identifies far more ADRBs than clinical assessment 20.4% of people prescribed opioids for pain had either no opioid in urine, or additional non-prescribed opioids

  19. (ex)Heroin users seek prescribed opioids To maintain their habit To manage withdrawal A less stigmatized alternative to OST To sell to the black market To relieve pain and distress

  20. Pain and Addiction often coexist Addicted lifestyle may contribute to chronic pain (injuries, ulcers, neglect) Opioid-induced hyperalgesia, emotional dysregulation, and somatic focusing Comorbid demoralisation and social marginalisation increase distress Chronic or recurrent opioid withdrawal

  21. Mx of Pain in (ex)addicts Structured treatment Realistic objectives Supervised dispensing Monitoring of injecting sites Urine toxicology

  22. Mx of Pain in (ex)addicts Structured treatment Realistic objectives Supervised dispensing Monitoring of injecting sites Urine toxicology But first, identify (ex) addicts Drug use history, Focused physical examination

  23. 3. Recreational drug users and opioid analgesics Tramadol frequently prescribed in UK, and rising tramadol overdose deaths are a distinct UK issue 2012 Global drug survey (internet) covered tramadol 7360 UK respondents (mean age 29, 90% white, 90% working or studying) Past-year drug use Cocaine 32%, heroin 0.9%, tramadol 5.6%

  24. Recreational drug users and opioid analgesics Source of acquisition of tramadol (N = 369) N (%) Prescribed to me 235 (63.7) From a friend 124 (33.6) From a dealer 12 (3.3) From the internet 10 (2.7)

  25. Reasons given for using tramadol N (%) To relieve pain 276 (74.8) To help me relax 114 (30.9) To help me sleep 104 (28.2) To get high 91 (24.7) To relieve boredom 58 (15.7) To relieve distress 38 (10.3) For work 21 (5.7) For socialising 17 (4.6) To relieve withdrawal 12 (3.3) For sex 7 (1.9) For study 5 (1.4) Other function 29 (7.9)

  26. Reasons given for using tramadol Overall: 44% reported reasons other than analgesia 28% combined tramadol with alcohol or other drugs to enhance its effect 19% took doses higher than prescribed 10% reported difficulty stopping

  27. Summary Among young, socially-integrated people sharing and misuse of prescribed pharmaceuticals is not rare in UK Trend towards normalisation of drug use In US, this trend among high-school students and late adolescence appears to have contributed to increasing dependence on pharmaceutical opioids

  28. Management of chronic pain 1. Assessment addiction history social functioning examination of veins urine toxicology (UDS) 2. Formulation and treatment objective NOT pain free

  29. Mx II 3. Structured Treatment Universal precautions Rationale for prescribing Rationalisation of prescribing Expectations – attendance, monitoring, review Dispensing arrangements - supervision Shared information with other involved doctors

  30. References Dasgupta N, Kramer D, Zalman M, Carino S, Smith MY, Haddoxa JD, Wright C (2006) Association between non-medical and prescriptive usage of opioids Drug and Alcohol Dependence 82 ; 135–142 FishbainDA, Cole B, Lewis J, Rosomoff HL, Rosomoff RS (2008) What Percentage of Chronic Nonmalignant Pain Patients Exposed to Chronic Opioid Analgesic Therapy Develop Abuse/Addiction and/or Aberrant Drug-Related Behaviors? A Structured Evidence-Based Review Pain Medicine 9; 4: SAMHSA (2012) A Treatment Improvement Protocol. TIP 54 Managing Chronic Pain in Adults With or in Recovery From Substance Use Disorders. Substance Abuse and Mental Health Services Administration, Rockville, MD. Bell J, Reed K, Gross S, Witton J (2013) The Management of Pain in people with a past or current history of addiction Action on Addiction, London Winstock, A., Bell, J., Borschmann, R. (2014) The non-medical use of tramadol in the UK: findings from a large community sample International Journal of drug Policy doi: 10.1111/ijcp.12429

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