BALANCING PAIN RELIEF AND RISK FOR ADDICTION
Aberrant Drug-Taking Behaviors During Pain Management—What Do We Know?
Steven D. Passik, Ph.D.
Clinicians who use opioid analgesics to treat people with chronic pain must monitor outcomes in four domains. Monitoring the so-called 4 A’s (analgesia, activities of daily living, adverse effects, and aberrant drug-taking behaviors) is a way of codifying the success or failure of an opioid trial. No domain is more complex to assess and interpret than that of aberrant drug-taking. The more obvious behaviors, from the point of view of addiction or diversion, are often opaque and are certainly not routinely elicited in self-report. The less obvious behaviors are more common but ambiguous. Driven by multiple influences, these nonadherent behaviors are common; they may map on addiction or may represent several other alternatives. Emerging research suggests that aberrant behavior does map on addiction if it is repetitive or frequent, that it can be predicted by a range of new screening tools, and that it can be managed even in the highest risk patients. We present these various points and suggest risk management approaches based on these emerging data.
Safe and Effective Opioid Prescribing in the Internet Age
Nathaniel P. Katz, M.D., M.S.
We briefly cover the epidemiology of pain and prescription opioid abuse, focusing on the connections between opioid prescribing and the abuse problem as the 21st century Internet era emerges. The role of the Internet and related technologies in the prescription opioid abuse problem is highlighted. Although the problem of pain and opioid abuse is by now well known, there have been few clear calls regarding how the problem can be comprehensively addressed. In particular, physicians, particularly primary care physicians, have been left with obligations to both relieve pain and prevent abuse but have little guidance on how to navigate these “rocky waters.” We present a simple and pragmatic approach to safe opioid prescribing for physicians that take advantage of 21st century technology.