Management of the ongoing prescription-opioid health crisis in the United States will require a multifaceted approach. Federal authorities must find ways to reduce opioid use within a regulatory framework. Pharmaceutical companies should continue to seek ways to reduce inappropriate use through drug formulation, such as modifying drug delivery when oxycodone is crushed and snorted. Serious patient education on drug abuse liability before prescribing, by the way, remains uncharted water.
But our challenge as prescribing clinicians may be to overcome old drug stereotypes and established practice patterns. If an opioid is deemed to be clinically necessary for pain control, maybe we need to be less willing to prescribe some opioids in favor of others.
Drug dependence – defined clinically by tolerance and withdrawal – with long-term opioid use is a predictable but acceptable and manageable risk in the face of chronic pain. Drug abuse – defined clinically by aberrant behaviors and adverse psychosocial consequences – is what we should be striving to avoid. The national prescription drug–abuse problem makes life more difficult for patients who have legitimate needs for opioid pain control.
The opioids we use in clinical medicine are all euphorigenic, but select opioids are preferred among the drug-abusing population. In this regard, not all opioids are created equal. Drug abuse is more likely with drugs that give the user a sensation of euphoria or a "high."
Dr. Rachel Wightman of New York University and her colleagues recently published a review of the literature on "opioid likeability" and "opioid abuse liability" (J. Med. Toxicol. 2012;8:335-40).
The studies included in the review showed no clinical difference between abuse liability of morphine and hydrocodone, with similar subjective positive and negative effects. In contrast, oxycodone demonstrated high subjective attractiveness.
Although morphine may be associated with more side effects than oxycodone, it is an effective opioid analgesic that is half the strength of oxycodone. Would it be unreasonable for us to tell our patients that they will receive morphine or hydrocodone for pain control?
Some emergency departments have become "oxy-free." This will be more challenging in a continuity practice in which patients come prepackaged with oxycodone on board, but at least we could consider establishing "no new oxy" clinical zones.
Dr. Ebbert is a professor of medicine and primary care clinician at the Mayo Clinic in Rochester, Minn. He reported having no conflicts of interest. The opinions expressed are those of the author. Reply via e-mail at imnews@frontlinemedcom.com.