What are opioids and how do they work?

Opioids are drugs that are derived from opium. They inhibit pain signals by binding to opioid receptors and producing a feeling of analgesia (relief from pain). Opioid receptors are mainly found in the brain and spinal cord, but they are also present in the airways, lungs, and gastrointestinal tract. Examples of opioids include codeine, hydrocodone (Zohydro), oxycodone (OxyContin), morphine (Kadian, Roxanol), hydromorphone (Dilaudid), oxymorphone (Opana), meperidine (Demerol) and fentanyl (Duragesic).

What are opioids used to treat?

Opioids are most commonly used to treat acute pain that results from trauma or surgery as well chronic pain caused by cancer or other causes. 

Consequences of opioid abuse

Although opioids are effective pain relievers, they can cause dependence and addiction especially when used in the absence of significant pain. This is because they stimulate the region of the brain that produces feelings of pleasure, causing a person to want to take them repeatedly. Dependence refers to the need to continue taking a drug to avoid withdrawal symptoms. Addiction refers to the intense craving and compulsive use of a drug.

Opioid dependence, addiction, and abuse have led to drug diversion, crime, production of counterfeit drugs and overdose deaths. Drug diversion refers to the transfer of drugs from legal and medically necessary uses to those that are illegal, unnecessary or not medically authorized. Opioids are the most commonly prescribed class of medications in the US and are also the most commonly diverted. In 2008, opioids caused 14,800 overdose deaths. In general, they are responsible for 3 out of 4 prescription drug overdoses and the demand for opioids is increasing. Between 1992 and 2003, the number of people abusing prescription drugs increased from 7.8 to 15.1 million. Effective strategies for preventing or reducing the risk of opioid abuse should be implemented by providers and healthcare facilities.

What can physicians do to prevent or reduce the risk of opioid abuse?

There are several guidelines that physicians may adopt to prevent or reduce the risk of opioid abuse:

Patient evaluation

Physicians should consider the benefits and risks of opioid use for each individual patient, then develop an appropriate treatment plan. 

Physicians should conduct a thorough patient evaluation and document the medical indication for prescribing an opioid analgesic. The initial evaluation should identify:

• The cause, nature, history, location, intensity, and duration of the pain as well as the past and current treatments.
• The effect of pain on the patient’s physical and psychological functioning as well as work or relationships.
• Obstacles to treatment and rehabilitation such as a stressful home environment or lack of social support. 
• Any history of personal or family drug, medication or alcohol abuse. 

Determine the patients’ risk of drug misuse or abuse using validated screening tools such as the Screener and Opioid Assessment for Patients with Pain (SOAPP-R) or Opioid Risk Tool (ORT).

Screen for mental health disorders and depression as part of the initial evaluation.

Consider consultation with an addiction substance specialist before prescribing opioids to patients with a history of substance abuse.

Understand the role of replacement agonists such as methadone and buprenorphine in addiction treatment

Request past medical records directly from other providers to confirm previous evaluations and treatments.

Consult the state prescription drug monitoring program (PDMP) if available, and document results in the patient record.

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