The three worlds of prescription
opioid misuse
James Bell
November 2014
• Dr Bell has received funding for research studies, travel to
conferences, and hospitality, from ReckittBenckiser, ScheringPlough, Biomed P/L, Pfizer, Martindale, Titan
Pharmaceuticals, and Munipharma
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/nidanotes/2012/11/qa-dr-david-thomas
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
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)
Global problem
- Similar trends to US identified in Australia, Canada, Europe and Asia
Australian Opioid prescribing 1990s
700
600
500
Kg
400
Oral morphine
300
Methadone syrup
200
Other opioids
100
0
86 87 88 89 90 91 92 93 94 95
Year
Opioid overdose presentations to ED, Australia
(AIHW, 2008)
2500
2000
1500
Heroin + opium
Prescription opio
Methadone
1000
500
0
1998/1999
1999/2000
200/2001
2001/2002
2002/2003
2003/2004
2004/2005
2005/2006
2006/2007
An unprecedented epidemic of
prescription opioid misuse 19952010?
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
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 to Iowa Board of Health in 1885
(Quoted in Conrad and Schneider, 1992)
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
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
1. Prescription opioid dependence
Dependence on prescribed opioids and can
contribute to pain, disability and distress
Opioids contribute to pain through
1. Reinforcing unrealistic expectations
2. Withdrawal
3. OIH (Opioid Induced Hyperalgesia)
2. Diversion
Doctors prescribing patterns, USA 2009
Prescribing Patterns for All Prescribers
Percentile 10th
US Mean
50th
90th
• Prescriptions per Beneficiary
6
1
3
16
• Number of Pharmacies
32
1
17
85
• Percentage of Schedule II Drugs
4%
0%
0%
10%
•
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)
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
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 nonprescribed opioids
(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
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
Mx of Pain in (ex)addicts
Structured treatment
- Realistic objectives
- Supervised dispensing
- Monitoring of injecting sites
- Urine toxicology
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
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%
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)
Reasons given for using tramadol
To relieve pain
To help me relax
To help me sleep
To get high
To relieve boredom
To relieve distress
For work
For socialising
To relieve withdrawal
For sex
For study
Other function
N
276
114
104
91
58
38
21
17
12
7
5
29
(%)
(74.8)
(30.9)
(28.2)
(24.7)
(15.7)
(10.3)
(5.7)
(4.6)
(3.3)
(1.9)
(1.4)
(7.9)
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
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
Management of chronic pain
1. Assessment
•
•
•
•
addiction history
social functioning
examination of veins
urine toxicology (UDS)
2. Formulation and treatment objective
• NOT pain free
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
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
Fishbain DA, 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
•