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Recognizing opioid misuse and addiction

Opioid misuse

Opioid misuse refers to using opioids in ways other than intended by the prescribing physician, such as:

  • taking too much
  • altering the route of delivery
  • acquiring opioids from other sources (e.g., the street, double-doctoring).

Addiction and physical dependence

Many patients who take opioids daily are physically dependent, which means that they are tolerant to opioids and will experience withdrawal symptoms if the opioid is suddenly stopped.

Physical dependence is not the same as addiction. Most patients on opioids do not become addicted to them, even with long-term use. People are said to be addicted to a drug when they find its psychoactive effects so reinforcing that they have trouble controlling their use of the drug, and their drug use creates social, financial or psychological difficulties.

Addiction in patients with chronic pain

A recent systematic review (Vowles et al., 2015) estimated that the prevalence of opioid addiction in pain patients is eight to 12 per cent and the prevalence of opioid misuse is 21 to 29 per cent.

Aberrant drug-related behaviours, such as repeatedly running out of medication early, could indicate addiction, but could also be due to undertreated pain ("pseudoaddiction").

Identifying patients at high risk of addiction

The strongest predictor of addiction is current or past addiction to opioids or other drugs, such as alcohol, cocaine, benzodiazepines and cannabis (Fishbain et al., 2008). Other risk factors include:

  • age under 40
  • male sex
  • concurrent untreated mental illness, including anxiety disorders – particularly posttraumatic stress disorder – and mood disorders (Becker et al., 2008; Edlund et al., 2007; Wilsey et al., 2008)
  • family history of addiction.

Screening tools

The Opioid Risk Tool and the CAGE-AID are two short instruments that are useful for identifying patients at high risk of opioid addiction.

References

Becker, W.C., Sullivan, L.E., Tetrault, J.M., Desai, R.A. & Fiellin, D.A. (2008). Non-medical use, abuse and dependence on prescription opioids among U.S. adults: Psychiatric, medical and substance use correlates. Drug and Alcohol Dependence, 94 (1–3), 38–47.

Edlund, M.J., Steffick, D., Hudson, T., Harris, K.M. & Sullivan, M. (2007). Risk factors for clinically recognized opioid abuse and dependence among veterans using opioids for chronic non-cancer pain. Pain, 129 (3), 355–362.

Fishbain, D.A., Cole, B., Lewis, J., Rosomoff, H.L. & Rosomoff, R.S. (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), 444–459.

Vowles, K.E., McEntee, M.L., Julnes, P.S., Frohe, T., Ney, J.P. & van der Goes, D.N. (2015). Rates of opioid misuse, abuse, and addiction in chronic pain: A systematic review and data synthesis. Pain, 156 (4), 569–576. doi: 10.1097/01.j.pain.0000460357.01998.f1.

Wilsey, B.L., Fishman, S.M., Tsodikov, A., Ogden, C., Symreng, I. & Ernst, A. (2008). Psychological comorbidities predicting prescription opioid abuse among patients in chronic pain presenting to the emergency department. Pain Medicine, 9 (8), 1107–1117.