Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy

1: J Pain. 2007 May 10; [Epub ahead of print]

.Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD.
Department of Family Medicine, University of Wisconsin, Madison, Wisconsin.

The primary goal of this paper was to present a comprehensive picture of substance use disorders in a sample of patients receiving opioid therapy from their primary care physician. A second goal was to determine the relation of positive urine screens and aberrant drug behaviors to opioid use disorders. The study recruited 801 adults receiving daily opioid therapy from the primary care practices of 235 family physicians and internists in 6 health care systems in Wisconsin. The 6 most common pain diagnoses were degenerative arthritis, low back pain, migraine headaches, neuropathy, and fibromyalgia. The point prevalence of current (DSM-IV criteria in the past 30 days) substance abuse and/or dependence was 9.7% (n = 78) and 3.8% (30) for an opioid use disorder. A logistic regression model found that current substance use disorders were associated with age between 18 and 30 (OR = 6.17: 1.99 to 19.12), severity of lifetime psychiatric disorders (OR = 6.17; 1.99 to 19.12), a positive toxicology test for cocaine (OR = 5.92; 2.60 to 13.50) or marijuana (OR = 3.52; 1.85 to 6.73), and 4 aberrant drug behaviors (OR = 11.48; 6.13 to 21.48). The final model for opioid use disorders was limited to aberrant behaviors (OR = 48.27; 13.63 to 171.04) as the other variables dropped out of the model.

PERSPECTIVE: This study found that the frequency of opioid use disorders was 4 times higher in patients receiving opioid therapy compared with general population samples (3.8% vs 0.9%). The study also provides quantitative data linking aberrant drug behaviors to opioid use disorders.

PMID: 17499555 [PubMed – as supplied by publisher]

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3 Responses to Substance Use Disorders in a Primary Care Sample Receiving Daily Opioid Therapy

  1. There is also a great deal of confusion around terms that are associated with addiction. In many medical circles these confused terms often do not have any central connection to the real phenomenon of addiction. One good example of this problem is the term “physical dependence.” Physical dependence is often used as equivalent to addiction, and in fact, it is not equivalent at all. Physical dependence means that one’s body has become dependent on a substance. If that substance is taken away, there will be a reaction called “withdrawal.” Sometimes, withdrawal can even be life-threatening.

    There are many drugs that can cause physical dependence. Physical dependence is an intrinsic pharmacological property of a drug and many of the drugs that cause physical dependence are not addictive. One good example is clonidine, a medicine for high blood pressure. If clonidine is stopped suddenly, a life-threatening withdrawal reaction can occur. Surprisingly, drugs like morphine or other opioid medications, which also can cause physical dependence, usually don’t cause life-threatening withdrawal reactions. A familiar substance that often causes physical dependence is caffeine. This withdrawal reaction is typically manifested as a headache and can occur if one becomes accustomed to consuming caffeine and suddenly stops.

    Another common term that is associated with addiction but really has more to do with the pharmacological properties of a drug is that of “tolerance.” Tolerance means that a drug wears off in the patient’s body over time. Patients who have become tolerant to a medication need more and more of the drug to obtain the same effect. In other words, the same amount of the drug over time appears to deliver less and less effect. This again is a pharmacological property of a drug and is seen with many drugs and does not necessarily herald addiction as a problem.

    Unfortunately, many patients become very concerned about addiction when phenomena like physical dependence and tolerance are either possible or do occur. Unfortunately, many patients resist using medications that might help them because they equate the misconception of physical dependence or tolerance with addiction, which really is not the case.

  2. Physical Dependence or Addiction?
    Maia Szalavitz, May 14, 2007
    Distinctions are important when it comes to dealing with drug abuse, so why did the Archives of General Psychiatry confuse the press last week by misrepresenting a study in its journal?

    Last week, the Archives of General Psychiatry published a study finding that at some point during their lifetimes, 10.3% of Americans will suffer from disorders related to drug misuse.

    Unfortunately, the coverage that resulted was marred by a press release that incorrectly defined addiction, and then spun to suggest that the study shows a great need for expanded addiction treatment, which was not reflected in the actual data. Both errors show that when the media covers drugs, reporters are simply not paying attention.

    The erroneous addiction definition was picked up without question by Reuters, resulting in flawed reports on MSNBC, CNN and even the website of Scientific American.

    Defining addiction is not just an academic matter: it has profound implications for when it is legal to use certain medications to treat pain and, as a result, whether the 20-30 million Americans with severe chronic pain have access to appropriate treatment.

    The press release defined “substance dependence,” which is what addiction is called in psychiatry, as “physical dependence on a drug.” In fact, physical dependence on a drug is neither necessary nor sufficient to define addiction; people can become addicted to substances like cocaine, which does not produce physical dependence; they can also become physically dependent on blood pressure medications, which do not cause addiction.

    Unlike the press release, the actual study used the correct DSM definition of addiction, which boils down to compulsive use of substances despite ongoing negative consequences. The study also looked at the more common substance-related disorder, known as “substance abuse” which involves using drugs in potentially dangerous ways, but without being addicted to them.

    Virtually all pain patients who take opioid medications like morphine or Vicodin for long periods of time will become physically dependent, but only a tiny proportion of those without a history of drug problems will become addicts.

    Because it is illegal for doctors to “maintain” addicts on opioids (except under special circumstances using methadone or buprenorphine), defining addiction as physical dependence can suggest that treating chronic pain with opioids is illegal.

    Doctors who equate the two may deny adequate pain care to their patients, and patients can come to believe they are addicts when, in fact, they simply suffer physical dependence. Worse, doctors who try to treat pain aggressively may wind up incarcerated, when prosecutors who believe physical dependence and addiction are synonymous target them.

    Political reporters have been taking a great deal of flack lately for simply being stenographers; unfortunately, this story shows that the problem is not limited to politics.

    A spokesperson for the Archives of General Psychiatry (which is published by the American Medical Association) said in an email that the press release was “reviewed and approved by both the JAMA editors and the paper’s corresponding author.” While conceding that “our definition of dependence could have been more precise,” she said that a correction will not be forthcoming because “we don’t feel it is strictly inaccurate, in part because we refer to illicit substances – pain patients on prescribed or over-the-counter medications would not fall into this category.”

    Perhaps it is wrong to blame the press when medical authorities like the editors of one of the nation’s leading psychiatry journals are themselves unclear.

    But even the coverage that did not contain the misleading definition spun the story the way the National Institute on Drug Abuse presented it – as showing that most people with drug problems who “need” treatment do not get it.

    The study did find that only 38% of addicts ever received treatment for their disorder. However, it also showed that only 23% of those who had ever been addicted to drugs were currently addicted. This means that 77% recovered: just over double the amount who reported receiving treatment.

    More and better drug treatment is undoubtedly a good idea, but the data in the study really can’t be used to draw the conclusion that it is needed. The media needs to think carefully when it covers addiction, and not simply parrot the interpretations of research given in press releases.

  3. Pingback: University Update

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