Current Pain and Headache Reports

, Volume 15, Issue 2, pp 91–93

Maladaptive Opioid Use Behaviors and Psychiatric Illness: What Should We Do with What We Know?

Invited Commentary


It is well established that opioids are broadly effective for chronic pain. Although there is some agreement that stable, moderate dosing is desirable; longer-term management of patients with chronic pain often confronts clinicians with difficult decisions regarding when to intensify opioid treatment and when to declare failure. Under these circumstances the concern for addiction arises with uncomfortable frequency in specialty settings. An emerging literature has defined a number of plausible markers of risk for aberrant opioid use behaviors in clinical chronic pain populations. Some of these risk factors involve the presence of comorbid psychiatric illnesses, which puts clinicians in the difficult position of deciding whether or not to limit treatment to patients who are more complex. The authors discuss the issues of bad behavioral outcomes in opioid therapy, the implications of this emerging literature for clinicians, and suggest broad areas in which researchers can improve the knowledge base with which clinicians operate.


Chronic pain Opioid therapy Major depressive disorder Bipolar disorder Substance dependence 


  1. 1.
    Ballantyne JC, LaForge KS. Opioid dependence and addiction during opioid treatment of chronic pain. Pain. 2007;129(3):235–55.PubMedCrossRefGoogle Scholar
  2. 2.
    Chabal C, Erjavec MK, Jacobson L, Mariano A, Chaney E. Prescription opiate abuse in chronic pain patients: clinical criteria, incidence, and predictors. Clin J Pain. 1997;13(2):150–5.PubMedCrossRefGoogle Scholar
  3. 3.
    Passik SD, Portenoy RK, Ricketts PL. Substance abuse issues in cancer patients. Part 2: Evaluation and treatment. Oncology (Williston Park). 1998;12(5):729–34. discussion 36, 41–2.Google Scholar
  4. 4.
    Porter J, Jick H. Addiction rare in patients treated with narcotics. N Engl J Med. 1980;302(2):123.PubMedGoogle Scholar
  5. 5.
    Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain. 1986;25(2):171–86.PubMedCrossRefGoogle Scholar
  6. 6.
    Elander J, Lusher J, Bevan D, Telfer P. Pain management and symptoms of substance dependence among patients with sickle cell disease. SocSciMed. 2003;57(9):1683.Google Scholar
  7. 7.
    Elander J, Lusher J, Bevan D, Telfer P, Burton B. Understanding the causes of problematic pain management in sickle cell disease: evidence that pseudoaddiction plays a more important role than genuine analgesic dependence. JPain Symptom Manage. 2004;27(2):156.CrossRefGoogle Scholar
  8. 8.
    Saper JR, Lake 3rd AE, Hamel RL, Lutz TE, Branca B, Sims DB, et al. Daily scheduled opioids for intractable head pain: long-term observations of a treatment program. Neurology. 2004;62(10):1687–94.PubMedGoogle Scholar
  9. 9.
    Weissman DE, Haddox JD. Opioid pseudoaddiction–an iatrogenic syndrome. Pain. 1989;36(3):363–6.PubMedCrossRefGoogle Scholar
  10. 10.
    Koob GF, Le Moal M. Drug addiction, dysregulation of reward, and allostasis. Neuropsychopharmacology. 2001;24(2):97–129.PubMedCrossRefGoogle Scholar
  11. 11.
    Cami J, Farre M. Drug addiction. N Engl J Med. 2003;349(10):975–86.PubMedCrossRefGoogle Scholar
  12. 12.
    Webster LR, Webster RM. Predicting aberrant behaviors in opioid-treated patients: preliminary validation of the Opioid Risk Tool. Pain Med. 2005;6(6):432–42.PubMedCrossRefGoogle Scholar
  13. 13.
    Butler SF, Budman SH, Fernandez K, Jamison RN. Validation of a screener and opioid assessment measure for patients with chronic pain. Pain. 2004;112(1–2):65–75.PubMedCrossRefGoogle Scholar
  14. 14.
    Fleming MF, Balousek SL, Klessig CL, Mundt MP, Brown DD. Substance use disorders in a primary care sample receiving daily opioid therapy. J Pain. 2007;8(7):573–82.PubMedCrossRefGoogle Scholar
  15. 15.
    Hall W, Degenhardt L, Teesson M. Understanding comorbidity between substance use, anxiety and affective disorders: broadening the research base. Addict Behav. 2009;34(6–7):526–30.PubMedCrossRefGoogle Scholar
  16. 16.
    Rush AJ, Trivedi MH, Wisniewski SR, Nierenberg AA, Stewart JW, Warden D, et al. Acute and longer-term outcomes in depressed outpatients requiring one or several treatment steps: a STAR*D report. Am J Psychiatry. 2006;163(11):1905–17.PubMedCrossRefGoogle Scholar
  17. 17.
    Lin PI, McInnis MG, Potash JB, Willour V, MacKinnon DF, DePaulo JR, et al. Clinical correlates and familial aggregation of age at onset in bipolar disorder. AmJPsychiatry. 2006;163(2):240.Google Scholar
  18. 18.
    Berk M, Dodd S, Callaly P, Berk L, Fitzgerald P, de Castella AR, et al. History of illness prior to a diagnosis of bipolar disorder or schizoaffective disorder. J Affect Disord. 2007;103(1–3):181–6.PubMedCrossRefGoogle Scholar
  19. 19.
    Fishman SM, Wilsey B, Yang J, Reisfield GM, Bandman TB, Borsook D. Adherence monitoring and drug surveillance in chronic opioid therapy. J Pain Symptom Manage. 2000;20(4):293–307.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  1. 1.Department of Psychiatry and Behavioral SciencesThe Johns Hopkins University School of MedicineBaltimoreUSA

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