Introduction
Chronic nonmalignant pain is a silent epidemic in the U.S. that affects approximately 116 million Americans.1 It is also the most common reason patients seek medical care, resulting in $635 billion annually in both medical costs and decreased work productivity.1
Although the physiology of chronic pain continues to be poorly understood, it has been identified as a disorder associated with many psychosocial conditions, including lack of appetite, depression, and sleep disturbances. Therefore, the use of a multimodal therapeutic plan is imperative in the treatment of patients experiencing chronic pain. Health care practitioners should ensure that all aspects of the chronic pain syndrome, including pathophysiology, functional impairment, and psychosocial needs, are addressed.2 Nonpharmacological options, such as massage therapy, physical and occupational therapy, biofeedback, guided imagery, and cognitive–behavioral therapy, have been shown to help decrease some of the overall pain complaints. Interventional therapies, such as nerve blocks, transcutaneous electrical nerve stimulation (TENS), and injectable medications, are also used in various situations. However, a therapeutic plan typically employs the use of non-opioid and opioid analgesics to help control the pain.
Opioid Use
An ongoing debate has revolved around the long-term use of opioids in the treatment of chronic nonmalignant pain.3 Some of the discussion stems from the lack of data supporting long-term opioid use because of a lack of efficacy, ongoing concerns about adverse effects, and the potential for opioid misuse and abuse.4 Abuse and misuse of these medications remains a public health challenge, with abuse rates having quadrupled in the decade from 1990 to 2000.5,6 In addition, more than 70% of illegal users obtain opioids by stealing them, purchasing them illegally, or receiving them from family or friends.7 These individuals seek to achieve a "high" from prescription medications by taking an excess number of pills orally or by crushing the pills, followed by snorting, smoking, or injecting the new altered formulation.
By altering the prescribed formulation, many abusers seek to create what is known as the "dump" effect, or an acceleration associated with a rapid "high." The effect results in a much higher peak serum concentration (Cmax) over a shorter duration of time (Tmax). This pharmacokinetic change results in a pharmacodynamic response or in the abuser’s desired "reward" of euphoria. Therefore, each opioid should be examined for its potential abuse quotient (AQ = Cmax/Tmax). The abuse quotient can be reviewed to assess the rate of rise achieved by the drug in the blood and brain when the formulation is manipulated by an abuser.8
Conflict-of-Interest Statement (COI Policy)
Disclosure: Jefferson Medical College endorses the Standards of the Accreditation Council for Continuing Medical Education and the Guidelines for Commercial Support. Every effort has been made to encourage individuals to disclose any commercial relationships or personal benefit with commercial companies whose products are discussed in the educational presentation. Disclosure of a relationship is not intended to suggest or condone bias in any presentations but is made to provide participants with information that might be of potential importance to their evaluation of a presentation.
Dr. Moorman-Li, Dr. Motycka, Dr. Inge, Ms. Congdon, Ms. Hobson, and Mr. Pokropski report that they have no financial or commercial relationships to disclose in regard to this article. The article contains discussion of commercial products or services and investigative or off-label uses.
Extended-release (ER) formulations hold a greater attraction for abusers than immediate-release (IR) formulations because of their per-dose level of drug.9 ER opioid formulations provide higher drug concentrations that can be manipulated. When ER formulations are altered, not only is there a more rapid onset of action (a shor...
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