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David Baxter PhD

Late Founder
Avoiding Opioid Abuse While Managing Pain
by Frederick W. Burgess, MD, PhD

Book Review: Avoiding Opioid Abuse While Managing Pain
by Lynn R. Webster, MD and Beth Dove
Sunrise River Press, 2007
ISBN-13 978-0-9624814-8-2

Opioid analgesics represent one of our earliest and most effective therapeutic classes of medication. Despite their recognized efficacy, the opioids have historically been subjected to periods of widespread availability and abuse, followed by periods of excessive governmental restriction and legal oppression. Medical professionals have struggled, and still struggle, to determine the proper balance between the potential for opioid abuse and the need for compassionate analgesia.

Dr. Lynn Webster, a distinguished researcher and clinician specializing in pain medicine and psychiatry, and his associate, Beth Dove, a medical writer, have created a very useful compilation of information relating to the issues of pain treatment and the potential for opioid abuse and drug diversion in their text: Avoiding Opioid Abuse While Managing Pain. Dr. Webster is a recognized leader in the field of pain medicine and is noted for significant contributions to the pain medicine primary literature. Their text deals with a very timely topic, of considerable interest not only to pain medicine specialists but of great clinical relevance to primary care physicians engaged in the treatment of patients suffering from persistent pain conditions.

Avoiding Opioid Abuse While Managing Pain offers a concise overview of the overlapping issues of opioid abuse, the neurobiology of addiction, the assessment and monitoring for opioid abuse, and the legal ramifications of opioid prescribing. The text is concise, easy to read, and well organized. Numerous tables, figures, and graphic illustrations are included, emphasizing important points and pathways in addition to the reproduction of several diagnostic screening tools. Unfortunately, some of the graphics appear to have originally been designed as color slides and lose some of their clarity when reproduced in gray-scale for the text.

Webster and Dove open the book by defining many of the terms specific to addiction and drug dependence. The first chapter highlights the recent upsurge in prescription opioid abuse and accidental prescription drug overdose deaths, which appears to correlate with, but cannot be directly attributed to, the increased prescribing of opioid analgesics.

Based on current data, the greater availability of prescription opioids within the community may be providing increased opportunity for opioid diversion. One important point emphasized by the authors is that abuse and addiction are not synonymous; opioid abuse may be medically appropriate, in the sense that the patient may be using the medication to self-treat pain, but it qualifies as abuse if the medication was not prescribed to this individual.

For example, many teenage girls will use hydrocodone obtained from parents or friends to self-medicate a headache. They are not addicted or abusing it in the sense of "getting high," but simply using it to relieve their headache pain. However, from a strictly legal standpoint, this type of use is regarded as drug abuse. Much of the data published on this topic has used this type of definition. It tends to inflate the numbers of college students "abusing" drugs, but it is the accepted definition.

In the next chapter, the authors provide a general review of the current research on the neurobiology of addiction. The information presented cites many of the current developments in our understanding of addiction, but it may leave the reader more confused than enlightened. The problem is not with Webster and Dove's presentation; rather, it reflects the current lack of a unifying theory of addiction. Considerable advancements have been made in the field, but the manifestation of addiction is a complex mix of various genetic elements, environment, and drug-specific effects.

Webster and Dove go on to examine patient-specific behaviors as indications of opioid abuse patterns. Medication use behavioral patterns must be assessed and charted, much as any sign or symptom, and used to evaluate treatment response. The concept of a "trio-diagnosis" is proposed to account for the interactions between pain, psychiatric disease, and substance abuse.

The authors note that no single medical or mental health condition can be addressed independently and have a reasonable expectation of success. Comorbid diagnoses of substance abuse and psychiatric disease and pain are frequently manifested among patients with low back pain and in many other pain conditions. The 3 are often interrelated and may require the involvement of other medical specialists to obtain the best response. Simply prescribing an opioid to relieve pain has the potential to aggravate the other coexisting conditions.

Chapters IV and V of Avoiding Opioid Abuse While Managing Pain are devoted to identifying and assessing the risk factors that may contribute to opioid abuse. There is no single risk factor or screening tool that will uniformly identify a patient as a poor risk for opioid therapy. The main value of assessing these risk factors and applying an assessment tool lies in identifying which patient will require the greatest amount of supervision and careful ongoing monitoring for substance abuse.

Webster and Dove also present the advantages and limitations of several screening tools. They note that many of the early screening tests employed were specifically designed to diagnose alcohol or substance abuse and were not intended to assess patients employing opioids for pain. However, several new opioid-specific screening tools, such as the Opioid Risk Tool, the Screening Instrument for Substance Abuse, and the Prescription Drug Use Questionnaire, are reasonably fast and easy to administer. These tests will be useful in aiding physicians in developing a risk assessment protocol for their practice situations, to stratify patients according to their potential liability for addiction and substance abuse. As the authors point out: "the goal is not to deny pain treatment to any patient, but to set and maintain a level of monitoring proportionate to the individual's risk."

Chapter VI provides a number of specific methods for monitoring patients treated with opioid analgesics. Several factors are essential to avoid opioid abuse and diversion, some as simple as meticulous record keeping, a comprehensive history and physical assessment, continual re-evaluation and documentation of response, or lack thereof, and the use of an informed consent and treatment agreement signed by the patient. It is important to spell out the risks of chronic opioid therapy to the patient, provide standards of behavior relating to medication use, and delineate the patient's obligations to adhere to the agreed treatment protocol.

This chapter also delineates recommendations for monitoring and prescribing guidelines dependent on the perceived risk of opioid abuse/diversion risk for individual patients. It is essential that physicians prescribing opioids accept responsibility for both treating pain and avoiding harm that may be associated with their patients' abuse or diversion of opioid analgesics. Ethically and legally, the physician has a societal responsibility to evaluate and continually monitor for inappropriate opioid use.

The concept of a balanced approach to pain treatment and substance abuse is further elaborated in the next chapter. The perceived and real competing interests between appropriate pain treatment and the governmental focus on the war on drug abuse continue to inspire fear of prosecution among physicians.

The recent struggles between the pain medicine community and the Drug Enforcement Agency on how best to obtain balance have not provided a sense of confidence in the community. The authors have attempted to provide a guide to avoid legal scrutiny, but, realistically, there are no rigid criteria that can be uniformly applied to guard against it. Once again, the use of careful monitoring and documentation is the best approach. The book concludes with an overview of future directions targeting drug development and pharmaceutical delivery systems designed to minimize abuse potential.

Webster and Dove's Avoiding Opioid Abuse While Managing Pain will be a useful addition to the bookshelves of any physician or other healthcare provider engaged in the care of patients treated with opioids for persistent pain conditions. Increasingly, primary care physicians are responsible for treating patients with opioid addiction and persistent pain. This text will provide the necessary tools to develop treatment protocols for monitoring and documenting a careful program to assess the efficacy of chronic opioid therapy and minimize opioid abuse.
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