Extensive worldwide experience in the long-term management of cancer pain with opioid drugs has demonstrated that opioid administration in cancer patients with no histories of substance abuse is only rarely associated with the development of significant abuse or addiction.[1-11] Indeed, concerns about addiction in this population are now characterized by an interesting paradox. Although the lay public and inexperienced clinicians still fear the development of addiction when opioids are used to treat cancer pain, specialists in cancer pain and palliative care widely believe that the major problem related to addiction is the persistent undertreatment of pain driven by inappropriate fear of addiction.

The experience in the cancer population has contributed to a desire for a reappraisal of the risks and benefits associated with the long-term opioid treatment of chronic nonmalignant pain.[12,13] The traditional view of this therapy is negative. Early surveys, which noted that a relatively large proportion of addicts began their addiction as medical patients who received opioid drugs for pain, provided some indirect support for this perspective.[14-16] The most influential of these surveys recorded a history of medical opioid use for pain in 27% of white male addicts and 1.2% of black male addicts.[16]

Surveys of addict populations, however, do not provide a valid measure of the addiction susceptibility associated with chronic opioid therapy in populations without known abuse histories. Prospective patient surveys are needed to define this risk accurately. The Boston Collaborative Drug Surveillance Project evaluated 11,882 inpatients who had no histories of addiction and were administered an opioid while hospitalized; only four cases of addiction could be identified subsequently.[17] A national survey of burn centers could find no cases of addiction in a sample of more than 10,000 patients without histories of drug abuse who were administered opioids for pain,[18] and a survey of a large headache clinic identified opioid abuse in only 3 of 2,369 patients admitted for treatment, most of whom had access to opioids.[19]

Other data suggest that the typical patient with chronic pain differs significantly enough from the addict without painful disease that the risk of addiction during therapy for pain is low. For example, surveys of cancer patients and postoperative patients indicate that euphoria (a phenomenon believed to be common during the abuse of opioids) is extremely uncommon following administration of an opioid for pain; dysphoria is observed more typically in those who receive meperidine.[20] Although the psychiatric comorbidity identified in addict populations could be an effect, rather than a cause, of the aberrant drug taking, the association suggests the existence of psychologic risk factors for addiction. The likelihood of genetically determined risk factors for addiction has also been suggested by a twin study that demonstrated a significant concordance rate for aberrant drug-related behaviors.[21]

Overall, the evidence generally supports the idea that opioid therapy in patients with chronic pain and no histories of abuse or addiction can be undertaken with a very low risk of these adverse outcomes. This is particularly so in the older patient, who has had ample time to reveal a propensity for abuse. There is no substantive support that large numbers of individuals with no personal or family histories of abuse or addiction, no affiliations with substance-abusing subcultures, and no significant premorbid psychopathologies will develop abuse or addiction when administered potentially abusable drugs for medical indications.

The inaccurate perception that opioid therapy always has a high likelihood of addiction has encouraged assumptions that are not supportable in populations with no histories of substance abuse. For example, agonist-antagonist opioid analgesics are less likely to be abused by addicts than pure mu agonist opioids. Consequently, some clinicians view the agonist-antagonist drugs as safer in terms of addiction liability. There is no evidence for this conclusion in populations without drug abuse histories. Extensive experience with long-term opioid therapy for cancer pain and chronic nonmalignant pain [13,22-27] has relied on pure mu agonists. Similarly, there is a common perception that short-acting oral opioids and opioids delivered by the parenteral route carry a greater risk of addiction because of the rapid delivery of the drug. Again, these perceptions are derived from observations in the healthy addict population and are not relevant to the treatment of pain in medical patients with no histories of substance abuse.

References

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