QUESTION
AND
ANSWER SESSION
The symposium concluded with a short question and answer session that
reprised major points and provided additional insights. A summary of the
faculty’s collaborative responses is presented below.
Q: When should patients with emotional pain be
seen by a mental health provider?
A: If the patient is doing well with treatment and
demonstrating functional improvement in his or her
home, work, and social environments, then the
patient is benefiting from the current therapy even if
the underlying problem is emotional pain. Certainly
mental health approaches can be useful, but many
patients do not want them. This is a dilemma with
patients with chronic pain, because nearly all who
have had pain for several years could benefit from
cognitive-behavioral therapy or stress management.
Another barrier to cognitive-behavioral therapy is
inadequate insurance coverage. Nonetheless, if the
patient is not functioning well, the clinician should
encourage therapy.
Q: What are your thoughts on removing oxycodone from formularies and replacing it with new,
abuse-resistant oxycodone formulations?
A: It is premature to discuss that. First, there are no
such products on the market at this time. Second, even
when they are on the market, without more data, their
ability to reduce abuse remains theoretical. In addition,
because approximately 60% of recreational euphorigenic drug seekers obtain their drugs from family and
friends who have a legitimate prescription, it will be
challenging to identify which patients are good candidates to receive the abuse-resistant formulations.
Q: Where do you see fibromyalgia pain and tricyclic antidepressants and anticonvulsants?
A: Basically, there are 2 main patient populations in
chronic pain: those in whom there is a clear source of
chronic pain and those who have numerous symptoms
but no objective physiologic findings. Ultimately,
however, all behaviors have physiologic underpinnings. It is certainly evident that fibromyalgia is a condition whose underlying disease mechanism cannot be
16
clearly identified. In such patients, the psychosocial
dynamic tends to be more important, with cognitive
mechanisms important in treatment. This group is
also more likely to respond to tricyclic antidepressants
and anticonvulsants. Their response could be related
to underlying neuropathic pain or because the pain is
related to a mood disorder.
Q: Are there other medications that are red flags for
illicit opioid abuse when used in combination with
opioids? For example, medications that augment
the effects of the opioid?
A: Theoretically, this might be an issue. But it is
not a driving force behind abuse. It seems that there
are individuals with abuse-prone personalities. They
tend to be heavy smokers and are more likely to use
benzodiazepines and other medications as well as alcohol. In states that track data on overdose deaths,
approximately 50% involve both a benzodiazepine or
sleep aid with an opioid. Some patients seem to be
attracted to the combination.
Q: Why do more pain specialists use methadone
and experience less abuse concerns than with other
opioids?
A: Methadone is clearly a problematic drug. It represents approximately 33% of all deaths from opioids
yet just 5% of opioids prescribed for chronic pain.
The reasons for this fall into 2 categories. Between
1999 and 2001 media reports about the addiction and
abuse potential of oxycodone led many physicians to
stop prescribing it and switch to methadone. At the
same time, some insurers began requiring a
methadone trial before switching to oxycodone. The
problem is that physicians may be less unfamiliar with
methadone and its actions than with the actions of
other opioids. This is when you may have started to see
a rise in adverse effects and deaths secondary to
methadone.
Vol. 6, No. 1
n
July 2009