Fight ‘opiophopbia’ to give pain patients relief
Fight opiophopbia’ to give pain patients relief
Past dependence not always a contraindication
The use of opioids for pain relief is limited by what some have called "opiophobia," or the fear that patients will become addicted to the drugs. The Veterans Health Administration (VHA) has spelled out a means of addressing the drawbacks to opioid therapy and reducing the fear of prescribing opioids.
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Pain Management Agreement Opioid agreements should include discussion of:
Source: National Center for Ethics in Health Care, Veterans Health Administration, Washington, DC. |
First, physicians must be sure they understand the meaning of tolerance, dependence, substance abuse, addiction, and pseudoaddiction.
Tolerance, or neuroadaptation to the effects of opioids, and physical dependence can be expected with opioid use, but do not in themselves imply addiction.
Substance abuse is the use of a drug for nontherapeutic purposes or other than as intended.
Addiction is a pattern of behaviors including drug craving, compulsive use, continued use despite adverse consequences, and impaired control of drug use; pseudoaddiction is an iatrogenic condition resulting when undertreatment of pain causes patients to behave in ways that seem to suggest addiction, such as drug-seeking behavior.
Assess candidates for use
Physicians should assess patients with chronic pain that has not been relieved by other means to determine if they are candidates for opioids. If opioids are determined to be a clinically sound therapy, they should not be rejected because of their addictive properties alone, according to the VHA recommendations.
In assessing patients for opioid therapy, attention should be given to their history of pain relief medications, substance use or abuse history, and the complexity of their symptoms. Patients with pain and comorbidities (e.g., substance use disorders, psychiatric disorders) should be referred to pain specialists for evaluation and treatment, the VHA recommends.
VHA ethicists who researched the topic wrote that even patients with current or past history of drug abuse or addiction should not be automatically excluded from opioid therapy, and that the clinical ethical imperative "is clear: Like all other patients, patients with current or previous substance use or addiction are entitled to the most effective pain management attainable."
Formal agreements set goals, expectations
Formal pain management agreements among patients, family members or caregivers, and health care providers can be valuable tools for communicating expectations and goals. The VHA recommends agreements that establish realistic expectations and attainable goals, and educate patients, family, and caregivers about the risks and benefits of the drugs. The agreements should specify how the medication is to be dispensed and used, the terms for receiving opioid therapy, and the consequences should the agreement be breached. (See "Pain Management Agreement," right.)
Resource
- National Center for Ethics in Health Care, Veterans Health Administration. "Ethical considerations in opioid therapy for chronic pain." In Focus April 2005. Accessible on the web at www1.va.gov/vhaethics/download/InFocus/InFocus_April05.pdf.
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