EPIDEMIOLOGY OF OPIOID ADDICTION AND PAIN
Opioid Addiction in the United States: From Opium to the Internet
David F. Musto, M.D., M.A.
[Slides not available]
We briefly review the history of addiction in the United States, with an emphasis on the shifting attitudes concerning the treatment of patients with opioids.
Epidemiology of Chronic Noncancer Pain and Opioid Treatment
Mark Sullivan, M.D., Ph.D.
Pain intensity and associated distress in patients with nonmalignant pain is at least as high as in patients with cancer pain. A recent World Health Organization survey of primary care patients in 15 countries reported that 22 percent of patients had pain for at least 6 months that required medical attention or interfered significantly with their daily activities. The vast majority of these patients have pain that is not proportional to objective disease, such as back pain and headache. Yet 13 percent of headache patients and 18 percent of back pain patients in the United States report that they have been unable to work full time because of their pain. Between 1980 and 2000, the rate of opioid prescribing at U.S. outpatient visits for chronic musculoskeletal pain doubled, from 8 to 16 percent of visits. In 2001, approximately 3 percent of the general population was prescribed an opioid that they used regularly for at least 1 month. In models adjusted for demographic and clinical variables, persons with depressive and anxiety disorders (OR = 2.0) or problem drug use (OR = 3.0) in 1998 were more likely to report the regular use of prescribed opioids in 2001. These patients are precisely those who have been excluded as high risk for randomized trials of opioid efficacy.
History of Malignant Pain Treatment With Opioids
Kathleen M. Foley, M.D.
One-third of cancer patients in active therapy and two-thirds of patients with advanced disease, both adults and children, report pain that requires opioid analgesic therapy. National and international epidemiologic studies describe this consistent prevalence of cancer pain in both resource-rich and resource-poor countries.
Over the past 35 years, there has been a dramatic increase in the use of opioids for cancer pain patients based on the principle that opioid therapy is the first-line pharmacologic approach. The World Health Organization has championed the need for cancer pain relief and morphine as an essential drug in its palliative care initiatives, national cancer control programs, and more recently, in national AIDS strategies.
The chronic use of opioids in cancer patients has challenged the traditional views of opioid therapy for chronic pain. It has demonstrated that physical dependence is not a clinical issue for cancer patients. There is no limit to tolerance; opioid rotation can maximize analgesia and minimize side effects; and patients rapidly taper and discontinue use when their pain is effectively treated by specific cancer therapies. Drug misuse and abuse is rare, and two studies from India and the United States have demonstrated that the increased availability of opioids for a cancer population was not associated with prescription drug abuse.
Epidemiology of Prescription Opioid Abuse in Young Women: Relationship to Pain
Carol J. Boyd, Ph.D., M.S.N., R.N.
According to the 2005 National Survey on Drug Use and Health (NSDUH), approximately
7 percent of adolescents (7.4 percent girls and 6.3 percent boys) and 12 percent of young adults (11.3 percent women and 13.5 percent men) have engaged in the nonmedical use of prescription pain medications (NMUPD). The motivations of NMUPD vary; however, some motivations (but not all) are correlated with attendant substance abuse problems. Indeed, based on endorsed motivations, there appear to be two groups of nonprescription medication abusers—those characterized as “self-treatment” and the other characterized as “at risk.” The number of motives is associated with the number of potential substance abuse problems (positive DAST-10 scores) and, as the number of motives increase, so too does the likelihood of a positive DAST-10 score. In addition, the more motives endorsed, the greater the likelihood of concomitant marijuana and alcohol abuse. In NSDUH and more regional samples, most abusers get their drugs from a family member or friend, usually for free. Approximately 10 percent divert their parents’ medications. A higher percentage of women give away their prescription medications and are more likely to do so to same-sex friends. Further work is needed to establish whether the "friendly sharing" among family and friends poses a risk for developing substance abuse problems.