Saturday, August 14, 2010

Monitoring, Counseling Curb Rx-Opioid Misuse

Briefly NotedPatients with chronic pain who show aberrant drug-related behaviors, or an inclination toward such misbehaviors, often are denied treatment or discontinued from treatment when they are noncompliant with their use of prescribed opioid analgesics. New research demonstrates that close monitoring and substance-misuse counseling may facilitate compliance with opioid analgesic therapy in even the most difficult patients.

Researchers at the Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, conducted a randomized controlled trial in patients who were prescribed opioids for chronic noncancer back pain and who showed risk potential for or actual demonstration of opioid misuse [Jamison et al. 2010]. Forty-two patients meeting criteria for a high-risk of opioid misuse were randomized to either usual treatment (High-Risk Control, n=21) or experimental compliance treatment consisting of monthly urine screens, compliance checklists, and individual and group motivational counseling (High-Risk Experimental, n=21). An additional group of patients who met criteria indicating low potential for opioid misuse were recruited to second control group (Low-Risk Control, n=20). Patients were followed for 6 months and completed pre- and post-study questionnaires and monthly electronic diaries.

Outcomes were quite successful. Significant differences were found between groups with roughly 74% of the High-Risk Control patients demonstrating positive scores on a Drug Misuse Index (DMI), as compared with 26% from the High-Risk Experimental group and 25% from the Low-Risk Controls (p<0.05). The DMI represented a composite score of self-reported drug misuse (Prescription Drug Use Questionnaire), physician-reported abuse behavior (Addiction Behavior Checklist), and abnormal urine toxicology results. Therefore, the results of this study demonstrate support for the benefits of behavioral intervention in the management of opioid compliance among chronic back pain patients at high-risk for prescription opioid misuse.

COMMENTARY: Group sizes in this trial were quite small; however, as a proof of concept, it is important that the experimental compliance-motivating approach dramatically reduced aberrant drug-use behaviors to the level of patients without any predispositions to such opioid misuse. A caveat is that, while the outcomes were quite successful, the approach is time- and resource-intensive, and it can be difficult to standardize the delivery of effective motivational counseling. Further research along these lines, including cost-benefit analyses, may help to provide better direction for applying this sort of approach in appropriate clinical pain practices.

REFERENCE: Jamison RN, Rossa EL, Michna E, et al. Substance misuse treatment for high-risk chronic pain patients on opioid therapy: A randomized trial. Pain. 2010(Sep);150(3):390-400 [abstract here].