Commentary on Boscarino et al. (2010): Understanding the spectrum of opioid abuse, misuse and harms among chronic opioid therapy patients.
Commentary on Boscarino et al. (2010): Understanding the spectrum of opioid abuse, misuse and harms among chronic opioid therapy patients.
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对 Boscarino 等人的评论。
DOI：
10.1111/j.1360-0443.2010.03142.x
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发表时间：
2010
期刊：
影响因子：
--
通讯作者：
VonKorff,Michael
中科院分区：
文献类型：
--
作者：
VonKorff,Michael
In this issue, Boscarino et al.[1] report that one in four chronic opioid therapy (COT) patients in general practice met DSM-IV criteria for current opioid dependence. Since over five million Americans use COT on a regular basis while several million more chronic pain patients use opioids intermittently [2], understanding the extent of opioid abuse, misuse and opioid-related harms among COT patients is of clinical and public health significance. How does the high estimate of the prevalence of opioid dependence reported by Boscarino et al. compare to other estimates? A Cochrane review reported that only 0.27% of COT patients enrolled in randomized trials abused opioids [3]. Fishbain et al.’s [4] meta-analysis found that 3.3% of COT patients abused opioids, 11.5% had aberrant drug use behaviors, and 14.5% had illicit substances detected by urine drug screening. However, COT patients prescreened for substance abuse risk had very low rates of opioid abuse and aberrant drug use behaviors. Given these disparate results, it is not surprising that confusion reigns about the extent of opioid abuse, misuse and opioid-related harms among COT patients.Among COT patients enrolled in randomized trials, low rates of opioid abuse are likely due to careful pre-screening of patients and, in some trials, use of passive methods with poor sensitivity for detecting opioid abuse. Since screening of COT patients for abuse risk is often cursory in general practice, the low rates of opioid abuse among pre-screened COT patients reported in structured reviews [3, 4] are likely not generalizable to typical COT patients in primary care. However, DSM-IV criteria for opioid dependence have limitations in assessing opioid abuse among COT patients. Physiological dependence, tolerance, and withdrawal do not necessarily implicate a maladaptive pattern of substance use among chronic pain patients receiving medically prescribed opioids. Proposed DSM-V criteria do not consider either opioid tolerance or withdrawal among persons receiving medically prescribed analgesics in diagnosing opioid use disorder. For this reason, Boscarino et al.’s [1] prevalence estimate based on DSM-IV criteria is higher than would be found if opioid tolerance and withdrawal were ignored. In the absence of studies directly evaluating DSM-V criteria for opioid use disorder among COT patients, Fishbain et al.’s meta-analysis results [3] are useful, likely conservative, estimates of the extent of opioid abuse, aberrant drug use,
