Detecting Signs of Opioid Abuse and Treating the Addiction

Mei Ka Fong, PharmD Candidate; Heidi Roy, PharmD Candidate; Stephanie Sharkey, PharmD Candidate; and Kelly L. Matson, PharmD
Published Online: Monday, September 1, 2008

Ms. Fong, Ms. Roy, and Ms. Sharkey are PharmD candidates at the University of Rhode Island College of Pharmacy. Dr. Matson is a clinical associate professor at the University of Rhode Island College of Pharmacy, department of pharmacy practice.


Opioid dependence is an epidemic that has no prejudice or limits. The number of nonmedical users of narcotics has increased steadily over the years, making opioids one of the highest drug classes abused, second only to marijuana.1 By 2006, the number of users of nonmedical pain relievers was greater than cocaine and heroin users combined (5.2 million vs 2.4 million and 0.3 million, respectively).1 Pharmacists need to be informed and educated on opioid dependence, so they are able to recognize, confront, and recommend appropriate programs.

Classified as an addiction, opioid abuse is recognized in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, as a medical disorder with an etiology, pathogenesis, clinical presentation, diagnosis, and treatment options. Understanding the alteration of neurobiology in the brain, as well as the social dispositions that put opioid users at risk, encourages clinical diagnosis and treatment, rather than turning away a "drug seeker," who is judged to have arrived voluntarily at his or her condition.2,3

Warning Signs of Abuse

Sometimes, a legal and valid prescription spirals into an uncontrollable addiction. It is important, therefore, for pharmacists to recognize the signs of opioid abuse and help those patients who are struggling with the addictive properties of these drugs. Pharmacists should be wary of patients who insist on paying cash for their prescription pain reliever or those who may ask questions regarding the maximum dose of the drug or which drug "works better." If suspicious actions appear in a patient's profile—usually seen as consecutive narcotic refills from multiple prescribers—pharmacists should address this pattern with the patient and call the physician to recall any trends in office visits or complaints of increasing chronic pain.

The patient and prescription itself may serve as indicators of a suspected opioid abuser. Although not common, the opioid abuser may display symptoms of withdrawal, including agitation, paranoia, or other aberrant behavior. The prescription itself should be reviewed carefully, focusing on the quantity, strength, refill amounts, and prescription dates. If any part of the prescription looks suspicious, a call to the prescriber should be made to verify the order.

Resources for patients who are ready to address their addiction to opioids. A list of local clinics also should be available in the pharmacy at times of individual counseling.

Not every patient who comes into the pharmacy with a prescription for a controlled substance is an abuser; however, it is the pharmacist's responsibility to promote the patient's well-being and confront the patient who does show signs of dependence.4 In general, a constant watchful eye, review of medical history, and medication verification can help distinguish a drug abuser from a patient whose needs are medically necessary. Additionally, the code of ethics should remind pharmacists that a patient's well-being must be the center of professional practice.5 Trust needs to be established for the patient to share his or her struggles.

Confrontation of an opioid abuser can be unpredictable. Pharmacists need to reaffirm their commitment to the patient during this likely emotional time. If possible, direct the patient to the counseling room to avoid any public embarrassment. Maintain a calm demeanor, explain the legal and social consequences of abuse, and have brochures with information on local rehabilitation clinics and therapists who specialize in addiction readily accessible. Steady reassurance and empowerment of patients can only help them to make changes in their lives. It is not to say, however, that all patients will respond positively to the recommendations made for drug rehabilitation. If the patient turns hostile or shows signs of potential violence, it is better to walk away from the situation and signal security.

Addiction Treatment Programs

Although certain aspects of treatment require inpatient care, providing outpatient treatment is an increasing trend, and it is in this setting where pharmacists are more likely to interact with patients and play a role—not only in recognition of the disorder, but treatment.2,3

The goal of treatment is complete independence from addiction, resulting in improved personal relationships, workplace function, and role as a member of the community. Treatment includes multiple courses of behavioral and pharmacologic therapy, both of which are necessary to prevent relapse.6 Treatment location and duration should be tailored to each patient. Generally, pharmacotherapy will last for 180 days, whereas behavioral therapy may last for years, and, in some cases, indefinitely.2,3

Behavioral therapy is essential for recovery and health maintenance. It instructs the patient how to function without opioids, deal with cravings, avoid situations that may cause relapse, and how to handle a relapse if it occurs. Behavioral therapy also extends to friends, family, and spouses of the affected patient and focuses on developing a unified support network. It teaches the caregiver how not to be an enabler of addiction and helps address feelings and hardships that he or she may experience while the caring for the patient.2,3 Behavioral therapy includes individual counseling, cognitive-behavior therapy, support groups, recovery programs, and educational or informational classes.

Table
Medications for Treatment of Opioid Dependence

Drug

Recommended Dosing

Mechanism of Action

Place in Therapy

Naltrexone

50 mg po daily

Competitive opioid receptor antagonist

Induction of detoxification; maintenance

Buprenorphine

4-16 mg sublingually daily

Opioid receptor partial agonist

Induction; treatment of withdrawal following detoxification; maintenance

Methadone

20-120 mg po daily

Opioid receptor partial agonist

Treatment of withdrawal following detoxification; maintenance

Buprenorphine/ naloxone

4-16 mg buprenorphine/1-4 mg naloxone sublingually daily

Opioid receptor partial agonist/antagonist

Induction; maintenance

Adapted from references 2,3,7.


Withdrawal Pharmacotherapy

Pharmacotherapy addresses withdrawal symptoms caused by the cessation of an opioid in a dependent patient. These drugs are designed to either mimic or block the effect of opioids, allowing patients to taper off or discourage their use. The Table describes common medications used in the treatment of opioid addiction, recommended dosing, mechanism of action, and place in therapy.

Although recognition and treatment of opioid dependence is increasing, barriers to treatment remain. Social stigma associated with opioid addiction, denial, and embarrassment may prevent some patients from seeking appropriate help. They also may lack the proper support needed for therapy. Pharmacists, as an integral part of the health care team serving these patients, need to provide support and encouragement for patients seeking treatment.

As the last professionals in the health care system patients will encounter before they receive their medication, pharmacists should take the time to counsel patients on potential medication side effects and drug interactions, especially with prescription pain relievers. By doing so, education and trust is fostered, which will help fight the rising prevalence of opioid abuse.

References

  1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Results from the 2006 national survey on drug use and health: national findings. Accessed May 5, 2008. www.oas.samhsa.gov/nsduh/2k6nsduh/2k6results.pdf.
  2. National Institutes of Health, National Institute of Drug Abuse Research Reports Series. Prescription drugs abuse and addiction. Accessed April 22, 2008. www.drugabuse.gov/ResearchReports/Prescription/Prescription.html.
  3. Tommasello AC. Substance abuse and pharmacy practice: what the community pharmacist needs to know about drug abuse and dependence. Harm Reduct J. 2004 Apr 20;1:3. Accessed April 22, 2008. www.harmreductionjournal.com/content/pdf/1477-7517-1-3.pdf.
  4. American Association of Colleges of Pharmacy. Oath of a pharmacist. Accessed April 25, 2008. www.aacp.org/site/tertiary.asp?CID=290&DID=4339.
  5. US PharmD. Pharmacist code of ethics. Accessed April 26, 2008. www.uspharmd.com/pharmacist/Pharmacist_Oath_and_Code_of_Ethics.html.
  6. Torpy JM, Lynm C, Glass RM. JAMA patient page. Opioid abuse. JAMA. 2004 Sep 15; 292(11):1394.
  7. Gold Standard Inc. Clinical Pharmacology. Accessed April 22, 2008. www.clinicalpharmacology.com.


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