The elephant in the room: the problem of iatrogenic opioid use disorder is being ignored.
I attended the annual meeting of the American Psychiatric Association (APA) in May. Sadly, but unfortunately not surprisingly, there were very few presentations on the subject of pain and its management. Of these, with 3 exceptions, all dealt with pain tangentially-their primary focus was on prescription opioid use disorder. (The exceptions were a course on migraines and psychiatric comorbidity, a case conference, and a seminar on hypnosis and pain.) The APA seems to have concluded that psychiatrists have little to contribute to the care of patients with pain, apart from caring for comorbid mental disorders, primarily opioid use disorder.
None of the presentations dealt with the very important issue of iatrogenic opioid misuse. This is when a patient ends up abusing or becoming addicted to an opioid prescribed for a legitimate pain complaint. At all the presentations, the benefits of methadone and buprenorphine for the management of opioid use disorder were highlighted: the general message was the importance of increasing access to these two agents.
There was apparently virtual unanimity of support for the use of methadone and buprenorphine for opioid abuse and addiction and for the fact that both are also considered efficacious opioid analgesics. Thus, at one of the symposia, I finally asked whether these should be our first-line opioids. I drew a laugh from the audience by pointing out that if patients did become addicted to them, they would already be taking the appropriate treatment!
My question was meant to be a very serious one. I wanted to point out that there was an apparent disconnect between what was being presented and the real world of pain management.
One of the doctors in attendance, whose clinical work is in pain management, replied that while he had previously recommended methadone as an analgesic, he could no longer do so because it was “a tricky drug” to manage. Curiously, after the symposium ended and I was waiting to talk to one of the other panelists, I overheard another member of the audience ask this doctor if he no longer prescribed methadone for pain. The panelist replied, “No, I prescribe it all the time. I just don’t think other doctors should prescribe it.”
The other panelist who responded to my question, an anesthesiologist, stated that buprenorphine couldn’t be used as a primary analgesic because patients who were to undergo surgery might need to be given a drug such as fentanyl and the buprenorphine would interfere with its actions. What she didn’t say was that this issue would equally apply to patients being treated with buprenorphine for opioid use disorder.
Unfortunately, it isn’t only at APA meetings that the problem of iatrogenic opioid use disorder is ignored. A recently published article on the medication management of opioid use disorder, written by officials of several federal government agencies, including the directors of the National Institute on Drug Abuse and the Centers for Disease Control and Prevention, fails to make any mention of it.1
Because of a lack of recognition and studies, we have no real understanding about iatrogenic opioid use disorder. No one knows whether, with regard to biology and psychology, it is the same disorder as that among those who use opioids for nonmedical reasons. Nor do we have much information on the most effective treatments.
One of the major hindrances to research on iatrogenic abuse is the lack of a separate diagnosis identifying it. It was excluded from DSM-IV because the members of the substance-related disorders Work Group were uncertain it existed. Although there is now widespread acceptance among health care professionals who are involved in pain management that it does exist, this diagnosis was also excluded from DSM-5 despite the fact that it added a specifier to opioid use disorder for patients in maintenance therapy with methadone and buprenorphine.
I believe that without a separate diagnosis for iatrogenic opioid use disorder, it will be impossible for us to understand the problem or even to determine how common it is. Studies report that from 0% to 50% of patients who take opioids for chronic non-cancer pain become addicted.2
One of the few prospective studies on the problem reported that 24% of patients who were taking opioids for chronic pain for an average of 36 months became addicted.3 Although most screening instruments for determining whether a patient with pain will become addicted to opioids primarily base this likelihood on past histories of substance abuse, this study found that few of those who became addicted had any such history.
A recent article in JAMA describes the stigma of opioid use disorder, noting multiple factors why it is frequently ignored by health care professionals and thus is not appropriately treated.4 If there is a stigma to the diagnosis in those who are using these drugs for nonmedical reasons, there is an even greater one for those in whom the problem is iatrogenic.
If someone is said to have a DSM-5 opioid use disorder or is called an opioid abuser or addict, most clinicians and the lay public think of the illicit user who is looking for a way to get high and has never used the drugs for medical purposes. Few of us think of a person who may have started taking the opioid for a legitimate complaint and run into problems with it.
Applying a diagnosis of opioid use disorder can have serious unintended consequences for the patient because of its association with criminal behavior. To my mind, it is as unfair to use the same diagnosis for illicit and iatrogenic abusers and addicts as it would be to describe a person in whom an infection develops at an IV site while he or she is undergoing chemotherapy as being the same as one who is self-injecting heroin.
1. Volkow ND, Frieden TR, Hyde PS, Cha SS. Medication-assisted therapies-tackling the opioid-overdose epidemic. N Engl J Med. 2014;370:2063-2066.
2. HÃ¸jsted J, SjÃ¸gren P. Addiction to opioids in chronic pain patients: a literature review. Eur J Pain. 2007;11:490-518.
3. Bouckoms AJ, Masand P, Murray GB, et al. Chronic nonmalignant pain treated with long-term oral narcotic analgesics. Ann Clin Psychiatry. 1992;4:185-192.
4. Olsen Y, Sharfstein JM. Confronting the stigma of opioid use disorder-and its treatment. JAMA. 2014;311:1393-1394.