The CMAJ editorial about opioids and chronic pain, “Better management of chronic pain care for all,”1 refers to “myths about addiction” and states that the potential for addiction is “frequently exaggerated.”
The risk of opioid addiction in prescribing opioids for chronic pain is quantifiable2 and, in some cases, predictable.3 The Canadian Guideline for Safe and Effective Use of Opioids for Chronic Non-Cancer Pain4 recommends documentation of substance use history in a comprehensive assessment before prescribing opioids. A previous or current substance-use disorder increases the risk of opioid addiction upon exposure to the class of drug. If the choice is made to proceed with opioid treatment in such a case, additional monitoring can be put in place, and patients can be advised of the risk to ensure fully informed consent. Patients at very high risk can be advised that, if opioid therapy fails or if addiction behaviours emerge, methadone or buprenorphine maintenance treatment may become the only safe treatment choice.
The concept of universal precautions in pain medicine5 asserts that a minimum level of vigilance be applied to all patients who are prescribed opioids. Similar to infectious disease, opioid addiction may emerge in seemingly low-risk patients. Following universal recommendations in pain management and opioid prescribing, including risk assessment and monitoring addiction, creates the effect of containing the level of risk for all.
The argument could be made that, short of death due to intentional or unintentional opioid overdose, opioid addiction is the most significant adverse effect of long-term opioid therapy for chronic pain. Physicians who prescribe opioids for patients with chronic pain, especially to higher-risk patients, should be prepared to recognize and manage aberrant drug-related behaviours and opioid addiction. Management can include structured opioid therapy,6 referral for opioid maintenance with methadone or buprenorphine, or abstinence-based treatment. When opioid addiction is identified and treated appropriately, patients do very well and quality of life is restored.
Untreated addiction is a devastating illness, affecting all aspects of a patient’s functioning, and is sometimes fatal. We cannot dismiss this illness in considering whether to proceed with opioid therapy. The constructive route, as with managing adverse effects from any other class of drugs, is to be well equipped to recognize and manage a serious adverse effect should it arise.