Balance sought to help curb growing opioid abuse

At a recent conference hosted by the National Institutes of Health on the tension between the two problems, Nora Volkow, M.D., head of the National Institute on Drug Abuse (NIDA), cited statistics confirming that in 2006 Vicodin (hydrocodone bitartrate and aceta-minophen, Abbott) was the second most frequently abused drug by teenagers. In addition, in 2005 Vicodin and equivalent opiate formulations had more new abusers than did marijuana. And between 1999 and 2004, the number of overdoses in persons 15 to 24 years old doubled, with most of the overdoses ascribed to opiate analgesics.

Volkow emphasized, however, that the issue is particularly difficult, because these medications "are extremely useful for the treatment of pain and can be life-saving for many patients. So the issue requires much more knowledge to start with, and, in my perspective, cooperation between two fields that for many years have not really talked to each other."

Much of the meeting focused on how much more information is needed in order to use opioids well and avoid another historic opinion swing against their use.

Nathaniel Katz, M.D., M.S., director of the program on opioid risk management at Tufts Health Care Institute, noted that opioids don't work for everyone. In fact, he said, "the response rate in most clinical trials of opioids is probably in the 30% to 40% range of patients getting meaningful response." With opioid therapy, he continued, "it is part of the obligation of the physician to implement some sort of success criteria.... And if somebody is not benefiting from opioid therapy or can't comply with it, then get them off."

Steven D. Passik, Ph.D., associate attending psychologist at Memorial Sloan-Kettering Cancer Center in New York, said that in a 400-patient survey he and colleagues did, 45% of pain patients had some aberrant behavior. Most of it, however, was on the level of drug hoarding or aggressive complaining and not criminal behavior.

Obviously, he reasoned, not all 45% are addicts, but if you treat a lot of pain in your clinic, almost half the cases will present with some behavior that you are going to have to sort out. While there are no guides on spotting patients who should be watched for abuse problems, he said, "it would make sense that patients who have repeated behaviors would be the patients we might have to worry about."

Pamela Palmer, M.D., Ph.D., director of the PainCARE center at the University of California at San Francisco, called for better formulations and technologies to reduce abuse. "I can track a pair of socks through FedEx or UPS from New Jersey to California. Yet when I write my OxyContin script, I have absolutely no idea how it is used." She said she is working with engineers on trackable ways of dispensing opioids at home, such as using ultrasmall formulations packaged in dispensers to provide the physician with dosing history, similar to that for home glucometers. That kind of technology, she added, is important not only to check for purposeful abuse but also for "the tidal wave of older folks coming our way.

"It is inexcusable that we are using urine checks and pill counting" to detect drug abuse, Palmer contended.

Kathleen Foley, M.D., attending neurologist at Sloan-Kettering and a leading voice for palliative care, received loud applause when she said, "To me the urgent problem is the extraordinary lack of good and excellent treatments we have for patients with pain."

She went on to emphasize, "I have continuing concern that we are not using an evidence base for developing policy." She added, "We hardly need another backlash."

The day after the conference, NIDA announced that it is launching the first large-scale national study on a treatment for prescription opioid analgesics addiction. Researchers will test the use of combination buprenorphine and naloxone tablets (Suboxone, Reckitt Benckiser) in combination with a variety of models of drug counseling to wean patients off opioids.