Medical Use and Abuse of Opioid Analgesics
abstract & commentary
Source: Joranson DE, et al. Trends in medical use and abuse of opioid analgesics. JAMA 2000;283:1710-1714.
Joranson and colleagues examined prevalence of the medical use of five opioid analgesics known to be effective for the treatment of severe pain and the proportion of drug abuse related to these medications from 1990-1996. For data on trends in drug abuse, Joranson et al used the Drug Abuse Warning Network (DAWN), which is sponsored by the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health and Human Services. The network collects information on the medical consequences of the nonmedical use of drugs from emergency departments throughout the United States with the goal of identifying abused substances, monitoring patterns of abuse, and identifying health hazards associated with the use of abused drugs. Every report of individual drug abuse in the DAWN system is classified as a drug "mention." Joranson et al obtained data on the medical use of opioids from the U.S. Drug Enforcement Administration’s Automation of Reports and Consolidated Orders System (ARCOS), which monitors the distribution of controlled substances to hospitals, pharmacies, and licensed practitioners.
Although the use of opioids increased substantially during the study period, the percentage of total drug mentions attributable to opioids declined by 25% from 5.1% in 1990 to 3.8% in 1996. These data are consistent with several prior reports supporting the fact that the use of opioid analgesics for the treatment of severe pain is not associated with an increase in diversion for illegal purposes. Furthermore, opioid analgesics accounted for only 4% of the total DAWN mentions for the period of 1990-1996, suggesting that these drugs play a relatively minor role in the overall substance abuse problem in the United States.
Commentary
In a survey from the Eastern Cooperative Oncology Group, which identified physician attitudes and practice in the management of cancer pain, 61% of those surveyed were reluctant to prescribe opioids and 62% reported patient avoidance to take these medications as two of the multiple barriers that exist to effective cancer pain management (Von Roenn JH, et al. Ann Intern Med 1993;119:121-126). Fear of psychological dependence (i.e., addiction) to opioids and diversion of opioids to an illegal market remain major concerns of health care providers despite numerous studies that have reported a small to nonexistent incidence when used appropriately in the medical setting. In 1980, Porter and Jick reported an incidence of 0.03% (4 out of 11,882 patients) among hospitalized patients (Porter J, Jick H. N Engl J Med 1980;302:123). In addition, a recently published study of opioid availability at neighborhood pharmacies suggests that unequal access to potent analgesic medications poses a critical additional barrier (Morrison RS, et al. N Engl J Med 2000;342:1023-1026).
The study by Joranson et al dispels any fears that increasing opioid availability leads to diversion to an illegal market. For neurologists and other health care providers with ongoing concerns about such diversion, the data presented should help clinicians feel more at ease with following existing practice guidelines for the management of malignant and nonmalignant pain. —ac (Dr. Alan Carver is a Pain and Palliative Care Fellow in the Department of Neurology, Memorial Sloan-Kettering Cancer Center, New York, NY.)
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