Detecting Signs of Opioid Abuse and Treating the Addiction

Ms. Fong, Ms. Roy, and Ms. Sharkey arePharmD candidates at the University ofRhode Island College of Pharmacy. Dr.Matson is a clinical associate professorat the University of Rhode Island Collegeof Pharmacy, department of pharmacypractice.

Opioid dependence is an epidemicthat has no prejudiceor limits. The number of nonmedicalusers of narcotics has increasedsteadily over the years, makingopioids one of the highest drugclasses abused, second only to marijuana.¹ By 2006, the number of users ofnonmedical pain relievers was greaterthan cocaine and heroin users combined(5.2 million vs 2.4 million and0.3 million, respectively).¹ Pharmacistsneed to be informed and educated onopioid dependence, so they are ableto recognize, confront, and recommendappropriate programs.

Classified as an addiction, opioid abuseis recognized in the Diagnostic andStatistical Manual of Mental Disorders,Fourth Edition, as a medical disorderwith an etiology, pathogenesis, clinicalpresentation,diagnosis, and treatmentoptions. Understanding the alteration ofneurobiology in the brain, as well as thesocial dispositions that put opioid usersat risk, encourages clinical diagnosis andtreatment, rather than turning away a"drug seeker," who is judged to havearrived voluntarily at his or her condition.^2,3

Warning Signs of Abuse

Sometimes, a legal and valid prescriptionspirals into an uncontrollable addiction.It is important, therefore, for pharmaciststo recognize the signs of opioidabuse and help those patients who arestruggling with the addictive propertiesof these drugs. Pharmacists should bewary of patients who insist on payingcash for their prescription pain relieveror those who may ask questions regardingthe maximum dose of the drug orwhich drug "works better." If suspiciousactions appear in a patient's profile—usually seen as consecutive narcoticrefills from multiple prescribers—pharmacistsshould address this pattern withthe patient and call the physician torecall any trends in office visits or complaintsof increasing chronic pain.

The patient and prescription itself mayserve as indicators of a suspected opioidabuser. Although not common, theopioid abuser may display symptoms ofwithdrawal, including agitation, paranoia,or other aberrant behavior. The prescriptionitself should be reviewed carefully,focusing on the quantity, strength, refillamounts, and prescription dates. If anypart of the prescription looks suspicious,a call to the prescriber should be madeto 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.

• Narcotics Anonymous: www.na.org
• Nar-Anon (for spouses):www.nar-anon.org
• Buprenorphine Physician andTreatment Program Locator:www.buprenorphine.samhsa.gov
• National Institute on Drug AbuseFact Sheets for Parents of Teens:www.nida.nih.gov
• Yellow Pages (Drug Abuse &Addiction Information, TreatmentCenters, Information & ReferralServices, listed by state):www.bigyellow.com

Not every patient who comes intothe pharmacy with a prescription for acontrolled substance is an abuser; however,it is the pharmacist's responsibilityto promote the patient's well-being andconfront the patient who does showsigns of dependence.⁴ In general, a constantwatchful eye, review of medicalhistory, and medication verification canhelp distinguish a drug abuser froma patient whose needs are medicallynecessary. Additionally, the code of ethicsshould remind pharmacists that apatient's well-being must be the centerof professional practice.⁵ Trust needs tobe established for the patient to sharehis or her struggles.

Confrontation of an opioid abuser canbe unpredictable. Pharmacists need toreaffirm their commitment to the patientduring this likely emotional time. If possible,direct the patient to the counselingroom to avoid any public embarrassment.Maintain a calm demeanor, explain thelegal and social consequences of abuse,and have brochures with information onlocal rehabilitation clinics and therapistswho specialize in addiction readily accessible.Steady reassurance and empowermentof patients can only help them tomake changes in their lives. It is not to say,however, that all patients will respondpositively to the recommendations madefor drug rehabilitation. If the patient turnshostile or shows signs of potential violence,it is better to walk away from thesituation and signal security.

Addiction Treatment Programs

Although certain aspects of treatmentrequire inpatient care, providing outpatienttreatment is an increasing trend,and it is in this setting where pharmacistsare more likely to interact with patientsand play a role—not only in recognitionof the disorder, but treatment.^2,3

The goal of treatment is completeindependence from addiction, resultingin improved personal relationships, workplacefunction, and role as a member ofthe community. Treatment includes multiplecourses of behavioral and pharmacologictherapy, both of which are necessaryto prevent relapse.⁶ Treatmentlocation and duration should be tailoredto each patient. Generally, pharmacotherapywill last for 180 days, whereasbehavioral therapy may last for years,and, in some cases, indefinitely.^2,3

Behavioral therapy is essential forrecovery and health maintenance.It instructs the patient how to functionwithout opioids, deal with cravings,avoid situations that may causerelapse, and how to handle a relapse if itoccurs. Behavioral therapy also extendsto friends, family, and spouses of theaffected patient and focuses on developinga unified support network. It teachesthe caregiver how not to be an enablerof addiction and helps address feelingsand hardships that he or she may experiencewhile the caring for the patient.^2,3Behavioral therapy includes individualcounseling, cognitive-behavior therapy,support groups, recovery programs, andeducational 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 receptorantagonist

Induction of detoxification;maintenance

Buprenorphine

4-16 mg sublingually daily

Opioid receptor partial agonist

Induction; treatment of withdrawalfollowing detoxification;maintenance

Methadone

20-120 mg po daily

Opioid receptor partial agonist

Treatment of withdrawal followingdetoxification; maintenance

Buprenorphine/ naloxone

4-16 mg buprenorphine/1-4 mg naloxone sublinguallydaily

Opioid receptor partial agonist/antagonist

Induction; maintenance

Adapted from references 2,3,7.

Withdrawal Pharmacotherapy

Pharmacotherapy addresses withdrawalsymptoms caused by the cessation ofan opioid in a dependent patient. Thesedrugs are designed to either mimic orblock the effect of opioids, allowingpatients to taper off or discourage theiruse. The Table describes common medicationsused in the treatment of opioidaddiction, recommended dosing, mechanismof action, and place in therapy.

Although recognition and treatmentof opioid dependence is increasing, barriersto treatment remain. Social stigmaassociated with opioid addiction, denial,and embarrassment may prevent somepatients from seeking appropriate help.They also may lack the proper supportneeded for therapy. Pharmacists, as anintegral part of the health care teamserving these patients, need to providesupport and encouragement for patientsseeking treatment.

As the last professionals in the healthcare system patients will encounterbeforethey receive their medication,pharmacists should take the time tocounsel patients on potential medicationside effects and drug interactions,especially with prescription pain relievers.By doing so, education and trust isfostered, which will help fight the risingprevalence of opioid abuse.

References

• 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.
• 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.
• 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.
• American Association of Colleges of Pharmacy. Oath of a pharmacist. Accessed April 25, 2008. www.aacp.org/site/tertiary.asp?CID=290&DID=4339.
• US PharmD. Pharmacist code of ethics. Accessed April 26, 2008. www.uspharmd.com/pharmacist/Pharmacist_Oath_and_Code_of_Ethics.html.
• Torpy JM, Lynm C, Glass RM. JAMA patient page. Opioid abuse. JAMA. 2004 Sep 15; 292(11):1394.
• Gold Standard Inc. Clinical Pharmacology. Accessed April 22, 2008. www.clinicalpharmacology.com.