(dailyRx)
Chemical dependency and recovery in patients and physicians are closely examined in a series of articles and editorials in the July 2009 issue of Mayo Clinic Proceedings.
The subject is especially timely as the immense challenges, including potential tragedies, of prescription chemical addiction and abuse are being discussed.
Addiction to and abuse of prescription opioid drugs are prevalent, and they exact an immense toll on patients, physicians and society, according to Steven Passik, Ph.D., of the Department of Psychiatry and Behavioral Sciences at Memorial Sloan-Kettering Cancer Center in New York, in “Issues in Long-Term Opioid Therapy: Unmet Needs, Risks, and Solutions.”
Opioid drugs have been used by humans for thousands of years and are the longest continuously used class of medications, explains William Lanier, M.D., editor-in-chief of Mayo Clinic Proceedings. Dr. Lanier and Evan Kharasch, M.D., Ph.D., of the Department of Anesthesiology at Washington University in St. Louis, authored the editorial “Contemporary Clinical Opioid Use: Opportunities and Challenges.” It summarizes the recent increased interest in this drug category.
Opioid medications are chemicals that bind to specific receptors, particularly in the nervous system and gastrointestinal tract, to decrease perception of pain and reaction to pain, as well as to increase pain tolerance. Side effects include sedation, respiratory depression and constipation. When opioid consumption is ongoing, physical dependence can and will develop. This dependence, in turn, can lead to problematic withdrawal when the medication is abruptly discontinued. Dependence, coupled with the feeling of euphoria these drugs can produce, leads to abuse.
According to Dr. Lanier, the recent growing interest in opioids stems from five sources:
- Advances in the design of these drugs
- Expansion and innovation in methods of drug delivery
- Increased public awareness of pain management options and the appropriateness of aggressively treating pain as the “fifth vital sign” and pain relief as a fundamental human right
- Growing recognition of the serious consequences of opioid misuse, misadventure and addiction
- Medicolegal aspects of practitioners’ prescribing practices and legal consequences for under- or overprescribing
Severe chronic pain includes that produced by cancer and such noncancer conditions as back injury and surgery. Opioids are a cornerstone of pain management for individuals in these categories, according to Howard Smith, M.D., of the Department of Anesthesiology at New York’s Albany Medical College.
Health care professionals helping patients with chronic pain must balance aggressive treatment with the need to minimize the risks of misuse and abuse, according to Dr. Passik. In “A Comparison of Long- and Short-Acting Opioids for the Treatment of Chronic Noncancer Pain,” Charles Argoff, M.D., and Daniel Silvershein, M.D., both from Albany Medical College’s Department of Neurology, write that management of chronic noncancer pain, for example, requires the following actions by a health care provider:
- Comprehensively assessing the patient
- Establishing a structured treatment regimen or program
- Continually reassessing the pain condition and the response to therapy
- Continually appraising the patient’s adherence to the treatment
A colleague of Drs. Argoff and Silvershein, Dr. Smith stresses the importance of understanding the metabolism of opioids in individual patients.
Keen awareness by family and friends of potential addiction is crucial for physicians and other health care providers, not to mention the general public, who might be at risk, according to “Chemical Dependency and the Physician” by Keith Berge, M.D., of the Department of Anesthesiology at Mayo Clinic; Marvin Seppala, M.D., of the Hazelden Foundation in Center City, Minnesota; and Agnes Schipper, J.D., who is with the Mayo Clinic’s legal department. Long-term recovery and sobriety can be achieved with appropriate treatment, aftercare and monitoring, they add.
New opioid formulas designed to minimize abuse are now in late-stage development and could help, Dr. Passik says. These drugs are chemically designed to diminish euphoric effects, thus possibly reducing problematic use. For now, responsibility coupled with expertise, insight, diligence and compassion are among the components that can meet the challenges of opioid use in pain management, the authors agree.
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