Sunday, 7 July 2013

Understanding Opioid Addiction

Today's article from (see link below) looks at a survey of attitudes towards opioids among adults but especially among medical practitioners. The levels of ignorance are surprising and that is the important point in this post. People with severe neuropathy may well end up on opioids but realising that many doctors just aren't aware of the consequences and how to deal with possible addiction, puts the responsibility back on the patient to talk to their doctors carefully. Patients should always be monitored on opioids; even more so now when many doctors and pharmacies are finding their options limited by laws that don't take into account the nature of chronic pain and its treatment.
In his commentary, Dr. Leavitt points out that the survey was carried out by a drug company whose specialty is medicines used to treat opioid addiction and warns the reader to beware of bias. He also says that despite that, the survey provides some revealing and worrying data for chronic pain patients.

Survey Shows Opioid “Addiction” Misunderstood
Posted by SB. Leavitt, MA, PhD Wednesday, June 26, 2013

A new national survey found that both adults and primary-care physicians in the United States cling to a variety of misperceptions and stereotypes about opioid addiction that may affect the way the disease is diagnosed and those afflicted are treated. The survey conducted during January and March 2013 involved more than 1,000 adults, ages 26 to 49, and 200 physicians. A major objective was to understand current attitudes about addiction to opioids — whether prescribed or illicit —and treatment for the disease. Along with that, the survey revealed some surprising knowledge deficits among the public and healthcare providers.

As reported in a news release [here], the survey discovered that more than a third (35%) of the physicians — none of whom were certified to treat addiction via a DATA (Drug Addiction Treatment Act) 2000 waiver — admitted to not knowing much about opioid addiction; two-thirds (66%) attributed low education level as contributing to the disorder, while more than half (57%) said that low income was a likely cause. [Responses to survey questions were not mutually exclusive, so numbers may add up to more than 100%.]

Two-thirds of adult respondents (67%) indicated that they do not know much about opioid addiction. At the same time, 45% of adults and 30% of physicians believed that opioid addiction “is more of a psychological problem,” such as a poor lifestyle choice, than a chronic illness or disease. Nearly half of adults (44%) and most physicians (92%) associated prescription analgesics with opioid addiction, but inexplicably only 55% of adults and 69% of physicians associated heroin with opioid addiction.

Two-thirds of adults (68%) and a vast majority of physicians (87%) concurred that opioid addiction affects millions of Americans, and 76% of adults and 96% of physicians were aware that misuse or abuse of prescription opioid analgesics poses a significant burden on the U.S. healthcare system. The adult respondents and physicians almost unanimously agreed (≈90% in each group) that opioid addiction can happen to anyone.

In that regard, nearly half (47%) of all adults surveyed reported having a personal connection with addiction and 12% admitted to personally struggling with the disorder. The surveyors observed that this is greater than the percentages of persons with diabetes (7%) or cancer (3%) combined.

Why would those suffering from addiction refrain from seeking treatment? Stigma and fear may be major barriers, since more than 77% of adults and most physicians (93%) mentioned shame or embarrassment, fear that others will find out, and/or fear of putting life on hold as reasons people avoid treatment. Most of the survey respondents — 71% of adults and 85% of physicians — also believed that persons with addiction do not seek help because they think they can stop on their own.

The survey detected some important misperceptions and attitudes among physician respondents:
Only about a quarter of physicians (27%) were aware that any physician [who is properly licensed and certified] can prescribe medications to treat someone with opioid addiction.

Nearly a third (31%) wrongly believed that special certification (known as a Drug Addiction Treatment Act [DATA] 2000 waiver) was unnecessary for dispensing or prescribing certain FDA-approved medications for maintenance treatment of opioid addiction.

A small percentage (7%) also said that they prefer not to treat patients with addiction in any way. The most commonly cited reasons for this included: a) the patient population is too difficult to treat (78%), b) it would require too much paperwork or take up valuable office staff time (61%), and c) not wanting to be viewed as an “addiction practice” (55%).

The vast majority of adults (92%) and physicians (98%) optimistically believed that opioid addiction is treatable. Roughly two-thirds of both groups, adult respondents and physicians, believed the disease could be “cured”; yet only 35% of adults and 21% of physicians thought that a stay at a rehabilitation clinic would be effective. And, a majority of adults (56%) and physicians (69%) believed that most people in recovery from opioid addiction will experience a relapse. Most of the adults (83%) and physicians (92%) concurred that people recovering from opioid addiction need a long-term combination of medication and behavioral changes to be successful with treatment.

This extensive and data-rich survey was conducted online by Harris Interactive on behalf of Reckitt Benckiser Pharmaceuticals, a specialty company that manufactures and markets medications for treating opioid addiction (eg, Suboxone® [buprenorphine] sublingual film). Therefore, it is predictable that the survey is slanted toward examining a need for greater awareness and implementation of office-based medication assisted treatment, or MAT, for opioid addiction.

The sponsor was no doubt pleased that 58% of adult respondents and 73% of physicians said they strongly support the use of prescribed medications to treat opioid addiction. Yet, less than half of adults (44%) were aware that such medications prescribed by physicians could be an option.

Commercially sponsored surveys like this one are not peer reviewed and are always suspect in terms of the underlying motives and accuracy of findings. It also may be questionable whether the responses of merely 1,000 adults and 200 physicians representing vastly larger populations would have external validity, no matter how carefully respondents are selected and weighted to approximate overall populations.

There are some remarkable knowledge gaps evident in the survey data, particularly among the physician respondents. Additionally, several other points are worth noting:
Throughout the survey report — and, of course, in news media stories that merely reiterated the press release — the term “dependence” was used to denote “addiction.” In fact, the survey found that for three-quarters of adult respondents (75%) dependence and addiction were considered to be synonymous, as also was the case for a sizeable portion physicians (43%). [In all instances, we replaced “dependence” with “addiction.”]

This is a problem, because physiologic dependence (ie, tolerance and adverse withdrawal effects) is NOT the same asaddiction when it comes to opioids, and confusion of the two terms and conflation of the underlying clinical concepts has led to many innocent patients with chronic pain being accused of, and erroneously treated for, an addictive disorder that does not truly exist. This was discussed extensively in an earlier Pain-Topics UPDATE article [here].

It is surprising that a third of physicians thought that they could prescribe medications for treating opioid addiction without special approval (eg, DATA 2000 waiver); although, the survey did not assess how many actually were engaged in such unlawful prescribing. At the same time, only 7% indicated that they do not want to treat patients with addiction in their practices, which is somewhat puzzling in that it seems to be a small proportion.

Office-based medication assisted treatment, or MAT, for opioid addiction can be time consuming and challenging. The medications used — eg, buprenorphine with or without naloxone, methadone, naltrexone — are not wonder drugs and, despite the beliefs of two-thirds of adults and physicians that addiction can be “cured,” common thinking is that the disease of addiction can be put into remission but not permanently resolved or cured. MAT could be but one part of a therapeutic milieu — which may include psychologic counseling, lifestyle changes, 12-step group participation, and other modalities — for achieving a state of remission.

In the survey, most of the adults (83%) and physicians (92%) appropriately believed that people in addiction recovery need a long-term combination of medical care and behavioral changes to be successful. However, this sort of ongoing care may be beyond the purview of typical primary-care practices.

Certainly, more education of the public and healthcare providers on opioid addiction is much needed, as evidenced in the survey. The term “addiction” (and, erroneously, “dependence”) is much overused; particularly when applied to patients with chronic pain who are on long-term opioid analgesic therapy. Whether or not primary-care physicians should be the ones diagnosing and treating the disease of opioid addiction, just as they would care for patients with other chronic and sometimes life-threatening illness, could be debatable.

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