COMMENTARY

The Pitfalls of Opioids for Chronic Nonmalignant Pain of Central Origin

Stephen G. Gelfand, MD

Disclosures

February 25, 2002

Background

A serious medical and social problem today is under intense media, law enforcement, and regulatory scrutiny: the misuse and abuse of OxyContin (oxycodone) for chronic nonmalignant pain. This situation has made the drug difficult to obtain for many patients with malignant and other types of intractable chronic pain, and has recently influenced the US Food and Drug Administration to issue a black box warning to lessen the chance of inappropriate prescribing of this Schedule II narcotic.[1]

In addition to recent Drug Enforcement Agency (DEA) autopsy findings of nearly 300 OxyContin overdose deaths nationally since January 2000,[2] a large volume of patients with chronic nonmalignant pain have become dependent or addicted as a result of legitimate prescriptions written for OxyContin, as well as other opioids.

In a recent case,[2] the DEA suspended physician narcotic licenses and closed a South Carolina pain clinic for the excessive prescribing of OxyContin, although the physicians involved believed they were following current established standards.

How did this situation occur? In the first place, certain statements in the narcotic guidelines established by the Federation of State of Medical Boards[3] have received insufficient or cursory attention. These include the recommendations on the importance of psychological and substance abuse evaluations, the necessity for other treatments depending on the etiology of the pain and extent of psychosocial impairment, and the requirement for consultation with or referral to an expert for comorbid psychiatric disorders.

These are common omissions, particularly in rural environments, where the OxyContin problem first originated, and in which psychosocial factors receive less attention, resulting in fewer numbers of referrals to mental health providers. Even before OxyContin came on the market, however, another opioid, hydrocodone, was one of the most widely abused drugs, particularly in rural areas of the South.[4]

Clearly, the large volume of prescriptions and chronic use of OxyContin have increased the supply, availability, and opportunities for every type of abuse, while also filtering into our schools.[5] Contributing to this situation has been an attempt to expand the indications for opioid therapy to the entire spectrum of chronic pain, regardless of cause.

As a result of an organized educational and marketing campaign by the manufacturer of OxyContin and a number of pain societies, the message has spread that pain is often undertreated in general and that opioids are safe in most instances and should be prescribed more often for chronic pain of all types.[6,7] If restricted to patients with cancer or other forms of intractable peripheral pathology, the use of opioids would be more acceptable, but the message also was intended and has been used to justify opioid treatment for many patients with nonmalignant, nonstructural chronic pain.

Because chronic widespread pain and psychological distress in the general population are closely associated,[8] the indications for treatment with opioids have been expanded to patients with chronic pain of central affective origin, including those within the wide spectrum of fibromyalgia, one of the most common rheumatic disorders.

Thus, the indications for opioid therapy have been extended to this large, heterogeneous group closely associated with a wide range of psychological distress, including the affective spectrum disorders.[9] These vulnerable patients are especially at risk for the dangers of opioid therapy, especially in rural regions where insufficient attention is given to pain-generating and amplifying psychosocial factors, in lieu of a more patient-popular drug-oriented approach.

The current "pain revolution" has also broadened the use of opioid drugs for chronic pain by focusing on quantitative criteria such as degrees of pain (a largely subjective parameter), rather than on etiology. However, the degree of pain often correlates poorly with objective findings, and quantitative factors have different levels of significance for the types of chronic pain common to different specialties, eg, oncology compared with rheumatology. This broad approach does not account for the essential distinctions in the biological and psychological origins of chronic pain subgroups, which are important to understand in making informed therapeutic decisions.

Furthermore, the appeal to broaden the indications for opioids has also trivialized possible long-term adverse consequences, particularly of OxyContin.[6,7] Consequently, as cited above, a number of pain clinics have formed for the primary reason of prescribing analgesics, especially opioids, while at the same time frequently downplaying or disregarding nonpharmacologic approaches, including psychological testing and management necessary for a large number of the chronic pain population.

Thus, the combined effect of expanding the indications for opioid use and insufficient attention to guideline recommendations has facilitated the current environment of OxyContin abuse, which has grown into a major medical, social, and law enforcement problem in many rural areas, as well as in an increasing number of metropolitan regions throughout the country.

In the last several years, OxyContin abuse has spread and reached epidemic proportions. The extent of this situation, which often involves generally law-abiding citizens, was recently reported in special television broadcasts on both CBS News' 48 Hours (in a segment entitled "Addicted") and MTV's "True Life: I'm Hooked on OxyContin." Susan Zirinsky, executive producer of the 48 Hours segment, which aired on December 12, 2001, states that "the growing addiction to prescription painkillers is a story that is touching every age group, and its effects are often devastating."[10]

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