Addiction Disorders and Therapy

An estimate of the abuse potential of analgesic opioid drugs by adult non cancer patients – a mini review

*Wolfgang H Vogel
Department Of Psychiatry And Human Behavior, Jefferson Medical College, United States

*Corresponding Author:
Wolfgang H Vogel
Department Of Psychiatry And Human Behavior, Jefferson Medical College, United States
Email:wuvogel@aol.com

Published on: 2019-01-02

Abstract

Data obtained from this review suggest that the abuse potential of opioid drugs is greatly over estimated and few if any adult patients without mental problems or a history of drug misuse will become addicted to therapeutically prescribed opioid drugs or might die of an overdose. Thus, physicians should continue to prescribe these drugs if deemed medically necessary.

Keywords

Opioid drugs; adult non cancer patients; patients

Copyright: © 2019 Wolfgang H Vogel*

 

Introduction

While the abuse potential of various narcotic or opioid drugs has been estimated to be moderate or about 5% or less in the past [1-4], more recently concern has arisen that the abuse potential might be much higher than previously thought. To clarify this problem, this paper tried to estimate their abuse potential based on more recent studies.

Methods

The author searched PubMed from 2007 to 2018 for studies on the therapeutic use of opioid drugs using search terms like “opioid drug therapy”, “long term use of opioid drugs”, ”surgery and opioid drugs” or “chronic noncancer pain and opioid drugs”. The author selected all studies which documented initiation and in particular subsequent continued or long term use of opioid drugs by non-cancer patients with the later as a possible risk factor for drug abuse. Types of studies as being clinical follow-up investigations or reviews and status of the patients as being opioid naïve or not are indicated in the results. If available, data from individuals with a history of drug abuse were excluded. A standard meta-analysis was then performed on all studies.

Results

1- An open-label study of 106 patients being treated with hydrocodone for up to 76 weeks showed good pain relief but no cases of drug abuse were identified [5]. Thus, abuse potential was 0%.

2- A survey of 293 patients receiving 515 new opioid prescriptions showed that 61 (21%) progressed to an episodic and 19 (6%) progressed to a long-term prescribing pattern which was most frequently seen in patients with a history of substance abuse or nicotine use [6]. Thus, possible abuse potential was less than 6%.

3- A survey of 1,416 patients who had upper extremity surgery and were prescribed 24 pills of opioid drugs showed that patients consumed only a total of 8.1 pills. No refills were requested and no abuse was noticed [7]. Thus, abuse potential was 0%.

4- Two hundred thirty-three patients were followed post-surgery for up to three years after opioid therapy initiation and investigators reported no evidence of de novo addiction [8]. Thus, abuse potential was 0 %.

5- A survey of 10 643 patients who underwent bariatric surgery and who were not chronic opioid users pre-surgery showed that 421 or 4% became chronic opioid users during a 90 day post-surgery period [9] .Thus, possible abuse potential was 4%.

6- A group of 4946 patients who had cruciate ligament reconstruction were prescribed opioid analgesics post-surgery. After 1 year, 4.7 % were still using these drugs. Patients younger than 25 years of age and patients with prior drug use had an increased risk of refilling prescription [10]. Thus, the possible abuse potential was 4.7%.

7- A group of 27,636 patients being discharged after minor surgery with an opioid prescription were followed for 1 year and 7.7 % still used these drugs at this time. However, 383,780 patients were prescribed NSAIDs and 7.8% still needed these drugs at 1 year [11]. Thus, abuse potential (comparing 7.7% and 7.8%) was 0%.

8- A survey of 9596 workers‘ compensation claimants showed that 2741 study participants (28.6%) filled an opioid prescription more than 90 days from their date of injury; 1762 (18.4%) filled an opioid prescription more than 180 days and 902 (9.4%) filled an opioid prescription more than 1 year from their date of injury. Persistent use was as sociated with a concomitant pain diagnosis. No mention of apparent drug misuse was made [12]. Thus, abuse potential was 0%.

9- A group of 21,072 patients diagnosed with 5 types of chronic pains were given a prescription for Schedule II or III/IV opioid medications and were followed for more than 90 days. The authors classified these patients into 3 risk groups: low-risk patients comprised 72.5 percent, at-risk patients 25.4 percent, and actual opioid-abusers as 2.2 percent [13]. Thus, possible abuse potential was 2.2%

10- The opioid drug use of 17,391 patients which underwent cervical fusion was followed for one year. About 8 700 patient had not used drugs before surgery. Of these patients, about 47% filled a prescription 1 month following surgery but only 6.3% did so after one year [14]. Thus, possible abuse potential was 6.3%.

11- Evaluation of opioid use after total knee arthroplasty showed that 57% of 3993 patients who had used opioids before the operation still used these drugs one year later while only 2% of 2660 opioid naïve patients used such drugs after one year [15]. Thus, possible abuse potential was 2%.

12- A group of 1,353,902 persons with no history of substance abuse were initially treated with opioid drugs and 5.3% still used these drugs after one year albeit these individuals were the ones with the highest pain intensities [16]. Thus, possible abuse potential was 5.3%.

13- A retroactive study of 536,767 opioid-naïve patients who filled an opioid prescription showed that – age dependent – between 0.7 and 7 % became long term users with older individuals being more long term users.. Patients initiating with long-acting opioids had a higher risk of longterm use than those initiating with short-acting drugs [17]. Thus, possible abuse potential was on average 3.6%.

14- A survey of 104,839 hydrocodone/acetaminophen users and 2,2 million IR oxycodone users found that after 90 days about 1.7% of the first group and 1.9% of the second group were still using the drugs [18] .Thus, possible abuse potential was on average 1.8%.

15- Randomly selected records of 870 000 patients on opioid therapy in Germany showed that long term use occurred in only 1.3% of all of these patients [19]. Thus, possible abuse potential was 1.3%.

16- A survey of 4 028618 health claims in Germany found that long term opioid therapy occurred in only 0.8% of these patients [20]. Thus, possible abuse potential was 0.8%.

17- A review of 26 studies involving 4893 participants using transdermal, intrathecal and oral opioid drugs showed that only 0.27% of participants exhibited later signs of opioid addiction [21]. Thus, abuse potential was 0.27%.

18- Twenty studies involving 2,507 chronic pain patients with no previous or current history of abuse/addiction found that the percentage of risk for abuse/addiction was between 0.19% and 0.59% [22]. Thus, possible abuse potential was on average 0.34.

19- A group of 215,678 patients who received opioid prescriptions from low-intensity prescribers and a group of 161,951 patients who received such prescriptions from high-intensity prescribers showed that long-term opioid use at 12 months was significantly higher among patients treated by high-intensity prescribers (1.51%) than among patients treated by low-intensity prescribers (1.16%) [23]. Thus, possible abuse potential was on average 1.35%.

20- A survey of 285 opioid-naïve women who received an opioid drug after cesarean delivery found that 0.36% became persistent opioid users. Preexisting psychiatric comorbidity, certain pain conditions, and substance use/ abuse conditions predicted prolonged drug use [24]. Thus, possible abuse potential was 0.36%.

21- From a total of 39 140 patients discharged from a hospital after surgery, 19 256 received an opioid prescription. After 90 days, 1229 patients or 3.1% still continued the medication [25]. Thus, possible abuse potential was 3.1%.

22- A survey of 56 845 opioid naïve patients who obtained opioid drug prescriptions from various emergency depart ments showed a 1.8% risk factor of using these drugs long term [26]. Thus, possible abuse potential was 1.8%.

23- A cohort of 698 950 female patients were started on opioid therapy and 3% and 0.5% still used these drugs after 1 year and 3 years [27]. Thus, possible abuse potential was 0.5%.

Discussion

Out of 23 studies, 5 studies reported no misuse or aberrant drug use, 1 study found an abuse potential of 0.27 and 17 studies reported mostly long term use (up to 3 years) with no particular mentioning of drug abuse. A meta-analysis of the risk of long term use after opioid drug initiation resulted in a value of 2.1 %. However, it must be considered that long term use does not necessarily indicate drug abuse but could be necessitated by legitimate medical reasons. It is well known that chronic pain might need long term therapy and prolonged use after surgery could be explained by the fact that the procedure did not eliminate all existing pain. Many of the above studies consider these considerations as a major factor for long term use. Furthermore, while most studies rely on number of prescriptions issued, it is well known that some patients might fill a prescription but do not take the medication at all or only in part [28]. A survey by the author of 90 individuals who had received prescriptions for various opioid drugs fell into three groups with about one third filling the prescription but not taking the tablets, one third taking only about half the medication, and one third taking the full amount without refills [29]. Thus, the abuse potential is probably considerably lower than the estimated long term use of about 2.1%. These data suggest that the abuse potential of these opioid drugs is greatly over estimated and few if any adult patients without mental problems [30] or a history of drug misuse will become addicted to therapeutically prescribed opioid drugs or might even die of an overdose [31,32]. Thus, physicians should continue to prescribe these drugs if deemed medically absolutely necessary.

References

  1. Jamison RN, Raymond SA, Slawsby EA, et al. Opioid therapy for chronic non cancer back pain. A randomized prospective study. Spine (Phila Pa 1976) 1998; 23(23): 2591-2600.
  2. 2. Kalso E, Edwards JE, Moore RA, et al. Opioids in chronic non-cancer pain: systematic review of efficacy and safety. Pain 2004; 112(3): 372-380.
  3.  Cowan DT, Wilson-Barnett J, Griffiths P, et al. A randomized, double-blind, placebo-controlled, crossover pilot study to assess the effects of long- term opioid drug consumption and subsequent abstinence in chronic noncancer painpatients receiving controlled-release morphine. Pain Med 2005; 6(2): 113-121.
  4. Jensen MK, Thomsen AB, Højsted J. 10-year follow-up of chronic non-malignant pain patients: opioid use, health related quality of life and health care utilization. Eur J Pain 2006; 10(5): 423-433. 
  5. Dept family Medicine, Thomas Jefferson University, unpublished data. 
  6. Hooten WM, St Sauver JL, McGree ME, et al. Incidence and Risk Factors for Progression From Shortterm to Episodic or Long-term Opioid Prescribing: A Population-Based Study. Mayo Clin Proc 2015; 90(7): 850-856. 
  7. Kim N, Matzon JL, Abboudi J, et al. A Prospective Evaluation of Opioid Utilization after Upper-Extremity Surgical Procedures: Identifying Consumption Patterns and Determining Prescribing Guidelines. J Bone Joint Surg Am 2016; 98(20): e89. 
  8. Portenoy RK, Farrar JT, Backonja MM, et al. Longterm use of controlled-release oxycodone for non-cancer pain: results of a 3-year registry study. Clin J Pain 2007; 23(4): 287-299.
  9. Raebel MA, Newcomer SR, Bayliss EA, et al. Chronic opioid use emerging after bariatric surgery. Pharmacoepidemiol Drug Saf 2014; 23(12): 1247-1257. 
  10. Anthony CA, Westermann RW, Bedard N, et al. Opioid Demand Before and After Anterior Cruciate Ligament Reconstruction. Am J Sports Med 2017; 45(13): 3098-3103. 
  11. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med 2012; 172(5): 425-430. 
  12. O’Hara NN, Pollak AN, Welsh CJ, et al. Factors Associated With Persistent Opioid Use among Injured Workers’ Compensation Claimants. JAMA News Open 2018; 1(6): e184050.
  13. Coutinho AD, Gandhi K, Fuldeore RM, et al. Longterm opioid users with chronic noncancer pain: Assessment of opioid abuse risk and relationship with healthcare resource use. J Opioid Manag 2018; 14(2): 131-141.
  14. Pugely AJ, Bedard NA, Kalakoti P, et al. Opioid use following cervical spine surgery: trends and factors associated with long-term use. Spine J 2018; 18(11): 1974-1981.
  15. Hadlandsmyth K, Vander Weg MW, McCoy KD, et al. Risk for Prolonged Opioid Use Following Total Knee Arthroplasty in Veterans. J Arthroplasty 2018; 33(1): 119-123. 
  16. Shah A, Hayes CJ, Martin BC. Factors Influencing Long-Term Opioid Use Among Opioid Naive Patients: An Examination of Initial Prescription Characteristics and Pain Etiologies. J Pain 2017; 18(11): 1374-1383.
  17.  Deyo RA, Hallvik SE, Hildebran C, et al. Association Between Initial Opioid Prescribing Patterns and Subsequent Long-Term Use Among Opioid-Naïve Patients: A Statewide Retrospective Cohort Study. J Gen Intern Med 2017; 32(1): 21-27. 
  18. DeVeaugh-Geiss A, Kadakia A, Chilcoat H, et al. ARetrospective Cohort Study of Long-Term Immediate-Release Hydrocodone/Acetaminophen Use and Acetaminophen Dosing Above the Food and Drug Administration Recommended Maximum Daily Limit Among Commercially Insured Individuals in the United States (2008–2013). J Pain 2015; 16(6): 569-579. 
  19. Marschall U, L’hoest H, Radbruch L, et al. Long-term opioid therapy for chronic non-cancer pain in Germany. Eur J Pain 2016; 20(5): 767-776. 
  20. Häuser W, Schubert T, Scherbaum N, et al. Guideline-recommended vs high-dose long-term opioid therapy for chronic non cancer pain is associated with better health outcomes: data from a representative sample of the German population. Pain 2018; 159(1): 85-91. 
  21. Noble M, Treadwell JR, Tregear SJ, et al. Long-term opioid management for chronic noncancer pain. Cochrane Database Syst Rev 2010; (1): CD006605.
  22. Fishbain DA, Cole B, Lewis J, et al. 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 Med 2008; 9(4): 444-459. 
  23. Barnett ML, Olenski AR, Jena AB. Opioid-Prescribing Patterns of Emergency Physicians and Risk of Long-Term Use. N Engl J Med 2017; 376: 663-673. 
  24. Bateman BT, Franklin JM, Bykov K, et al. Persistent opioid use following cesarean delivery: patterns and predictors among opioid-naïve women. Am JObstet Gynecol 2016; 215(3): 353. 
  25. Clarke H, Soneji N, Ko DT, et al. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ 2014; 348: g1251.
  26. Jeffery MM, Hooten WM, Hess EP, et al. Opioid Prescribing for Opioid-Naive Patients in Emergency Departments and Other Settings: Characteristics of Prescriptions and Association with Long-Term Use. Ann Emerg Med 2018; 71(3): 326-336. 
  27. Shah A, Hayes CJ, Martin BC. Characteristics of Initial Prescription Episodes and Likelihood of LongTerm Opioid Use — United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265-269. 
  28. Maughan BC, Hersh EV, Shofer FS, et al. Unused opioid analgesics and drug disposal following outpatient dental surgery: A randomized controlled trial. Drug Alcohol Depend 2016; 168: 328-334. 
  29. W H Vogel. Unpublished observations. 
  30. Kidorf M, Solazzo S, Yan H, et al. Psychiatric and Substance Use Comorbidity in Treatment-Seeking Injection Opioid Users. J Dual Diagn 2018; 17: 1-8. 
  31. Wolfgang H Vogel. The current opioid epidemic – a re-examination of all of its causes. Medical Research Archives 2018, 6(4): 1-12. 
  32. Wolfgang H Vogel. The contributions of 4 Narcotic Analgesics to Accidental Drug Overdose Deaths in One County in Florida from 1998 to 2017. J Drug Abuse 2018; 4(3): 1-4.