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Opioid Therapy in Patients with a History of Substance Abuse


A range of aberrant drug-taking behaviours can occur in patients who are undergoing treatment for chronic pain, especially if opioid therapy is involved. Assessing and understanding these behaviours, and their relationship to addiction (or substance use disorder), can be difficult but it is necessary for assuring quality pain management. Aberrant drug-taking behaviour may be evident, for example, when a patient with pain is unilaterally escalating doses of opioids or using the medications to treat other symptoms or when prescriptions are being mishandled. In patients with a history of substance abuse, these are often serious developments to which a clinician must know how to react. These complex behaviours may be indicative of addiction or may be simply a reaction to under-medicated pain. The clinician therefore is challenged to understand such behaviours and plan interventions accordingly.

Although it is becoming increasingly common to avoid opioid therapy in patients demonstrating such challenging behaviours for fear of regulatory scrutiny, clinical management can be tailored to address the many possibilities that might be giving rise to such behaviours. In addition, control over prescriptions can be accomplished without necessarily terminating the prescribing of controlled substances entirely. Optimal medical management of chronic pain in those patients with addiction problems or engaging in problematic behaviours involves careful, ongoing assessment by the clinician as well as a tailored management approach. This approach should use multiple structures including strict contracts, prudent drug selection and frequent follow-ups to pain and addiction treatments, including the use of urine toxicology screening, to maximise the likelihood of a good outcome.

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Fig. 1


  1. 1.

    Colliver JD, Kopstein AN. Trends in cocaine abuse reflected in emergency room episodes reported to DAWN. Public Health Rep 1991; 106: 59–68

  2. 2.

    Gfroerer J, Brodsky M. The incidence of illicit drug use in the United States, 1962–1989. Br J Addict 1992; 87: 1345–51

  3. 3.

    Regier DA, Myers JK, Kramer M, et al. The NIMH epidemiologic catchment area program. Arch Gen Psychiatry 1984; 41: 934–41

  4. 4.

    Wells KB, Golding JM, Burnam MA. Chronic medical conditions in a sample of the general population with anxiety, affective, and substance use disorders. Am J Psychiatry 1989; 146: 1440–6

  5. 5.

    American Psychiatric Association. Diagnostic and statistical manual for mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994

  6. 6.

    Dole VP. Narcotic addiction, physical dependence and relapse. N Engl J Med 1972; 286: 988–92

  7. 7.

    Martin WR, Jasinski DR. Physiological parameters of morphine dependence in man: tolerance, early abstinence, protracted abstinence. J Psychiatr Res 1969; 7: 9–17

  8. 8.

    Wilder A. Opioid dependence: mechanisms and treatment. New York: Plenum Press, 1980

  9. 9.

    Portenoy RK. Opioid tolerance and efficacy: basic research and clinical observations [abstract]. In: Gebhardt G, Hammond D, Jensen T, editors. Proceedings of the VII World Congress on Pain: progress in pain research and management. Vol. 2. Seattle (WA): IASP Press, 1994: 595

  10. 10.

    Foley KM. Clinical tolerance to opioids. In: Basbaum AI, Besson J-M, editors. Towards a new pharmacotherapy of pain. Chichester: John Wiley & Sons, 1991: 181

  11. 11.

    Ling GSF, Paul D, Simantov R, et al. Differential development of acute tolerance to analgesia, respiratory depression, gastrointestinal transit and hormone release in a morphine infusion model. Life Sci 1989; 45: 1627–36

  12. 12.

    Bruera E, Macmillan K, Hanson J, et al. The cognitive effects of the administration of narcotic analgesics in patients with cancer pain. Pain 1989; 39: 13–6

  13. 13.

    Twycross RG. Clinical experience with diamorphine in advanced malignant disease. Int J Clin Pharmacol 1974; 9: 184–98

  14. 14.

    Kanner RM, Foley KM. Patterns of narcotic drug use in a cancer pain clinic. Ann N Y Acad Sci 1981; 362: 161–72

  15. 15.

    Chapman CR, Hill HF. Prolonged morphine self-administration and addiction liability: evaluation of two theories in a bone marrow transplant unit. Cancer 1989; 63: 1636–44

  16. 16.

    France RD, Urban BJ, Keefe FJ. Long-term use of narcotic analgesics in chronic pain. Soc Sci Med 1984; 19: 1379–82

  17. 17.

    Portenoy RK, Foley KM. Chronic use of opioid analgesics in non-malignant pain: report of 38 cases. Pain 1986; 25: 171–86

  18. 18.

    Urban BJ, France RD, Steinberger EK, et al. Long-term use of narcotic-antidepressant medication in the management of phantom limb pain. Pain 1986; 24: 191–6

  19. 19.

    Zenz M, Strumpf M, Tryba M. Long-term opioid therapy in patients with chronic nonmalignant pain. J Pain Symptom Manage 1992; 7: 69–77

  20. 20.

    Redmond DE, Krystal JH. Multiple mechanisms of withdrawal from opioid drugs. Annu Rev Neurosci 1984; 7: 443–78

  21. 21.

    World Health Organization. Technical report no. 516, youth and drugs. Geneva: World Health Organization, 1973

  22. 22.

    Halpern LM, Robinson J. Prescribing practices for pain in drug dependence: a lesson in ignorance. Adv Alcohol Subst Abuse 1985; 5: 135–62

  23. 23.

    Dai S, Corrigal WA, Coen KM, et al. Heroin self-administration by rats: influence of dose and physical dependence [abstract]. Pharmacol Biochem Behav 1989; 32: 1009

  24. 24.

    Rinaldi RC, Steindler EM, Wilford BB, et al. Clarification and standardization of substance abuse terminology. JAMA 1988; 259: 555–7

  25. 25.

    Hay JL, Passik SD. The cancer patient with borderline personality disorder: suggestions for symptom-focused management in the medical setting. Psychooncology 2000 Mar–Apr; 9(2): 91–100

  26. 26.

    Khantzian EJ, Treece C. DSM-III psychiatric diagnosis of narcotic addicts. Arch Gen Psychiatry 1985; 42: 1067–71

  27. 27.

    Jorgensen L, Mortensen M-J, Jensen N-H, et al. Treatment of cancer pain patients in a multidisciplinary pain clinic. The Pain Clinic 1990; 3(2): 83–9

  28. 28.

    Moulin DE, Foley KM. Review of a hospital-based pain service [abstract]. In: Foley KM, Bonica JJ, Ventafridda V, editors. Proceedings of the 2nd International Congress on Cancer Pain: advances in pain research and therapy. Vol. 16. New York: Raven Press, 1990: 413

  29. 29.

    Schug SA, Zech D, Grond S, et al. A long-term survey of morphine in cancer pain patients. J Pain Symptom Manage 1992; 7: 259–66

  30. 30.

    Schug SA, Zech D, Dorr U. Cancer pain management according to WHO analgesic guidelines. J Pain Symptom Manage 1990; 5: 27–32

  31. 31.

    Ventafridda V, Tamburini M, DeConno F. Comprehensive treatment in cancer pain [abstract]. In: Fields HL, Dubner R, Cervero F, editors. Proceedings of the 4th World Congress on Pain: advances in pain research and therapy. Vol. 9. New York: Raven Press, 1985: 617

  32. 32.

    Ventafridda V, Tamburini M, Caraceni A, et al. A validation study of the WHO method for cancer pain relief. Cancer 1987; 59: 850–6

  33. 33.

    Walker VA, Hoskin PJ, Hanks GW, et al. Evaluation of WHO analgesic guidelines for cancer pain in a hospital-based palliative care unit. J Pain Symptom Manage 1988; 3: 145–9

  34. 34.

    World Health Organization. Cancer pain relief and palliative care. Geneva: World Health Organization, 1990

  35. 35.

    Health and Public Policy Committee, American College of Physicians. Drug therapy for severe chronic pain in terminal illness. Ann Intern Med 1983; 99: 870–3

  36. 36.

    Agency for Health Care Policy and Research, US Dept of Health and Human Services. Clinical practice guideline number 9: management of cancer pain. Washington, DC: US Department of Health and Human Services, 1994

  37. 37.

    Ad Hoc Committee on Cancer Pain, American Society of Clinical Oncology. Cancer pain assessment and treatment curriculum guidelines. J Clin Oncol 1992; 10: 1976–82

  38. 38.

    American Pain Society. Principles of analgesic use in the treatment of acute pain and cancer pain. Skokie (IL): American Pain Society, 1992

  39. 39.

    Zech DFJ, Grond S, Lynch J, et al. Validation of the World. Pain 1995; 63: 65–76

  40. 40.

    Portenoy RK. Opioid therapy for chronic nonmalignant pain: current status. In: Fields HL, Liebeskind JC, editors. Progress in pain research and management. Vol. 1. Pharmacological approaches to the treatment of chronic pain: new concepts and critical issues. Seattle (WA): IASP Publications, 1994: 247

  41. 41.

    Kolb L. Types and characteristics of drug addicts. Ment Hyg 1925; 9: 300–13

  42. 42.

    Pescor MJ. The Kolb classification of drug addicts. Public Health Rep 1939; 155 (Suppl.)

  43. 43.

    Rayport M. Experience in the management of patients medically addicted to narcotics. JAMA 1954; 156: 684–91

  44. 44.

    Porter J, Jick H. Addiction rare in patients treated with narcotics [letter]. N Engl J Med 1980; 302: 123

  45. 45.

    Perry S, Heidrich G. Management of pain during debridement: a survey of US burn units. Pain 1982; 13: 267–80

  46. 46.

    Medina JL, Diamond S. Drug dependency in patients with chronic headache. Headache 1977; 17: 12–4

  47. 47.

    Kaiko RF, Foley KM, Grabinski PY, et al. Central nervous system excitatory effects of meperidine in cancer patients. Ann Neurol 1983; 13: 180–5

  48. 48.

    Grove WM, Eckert ED, Heston L, et al. Heritability of substance abuse and antisocial behavior: a study of monozygotic twins reared apart. Biol Psychiatry 1990; 27: 1293–304

  49. 49.

    Buckley FP, Sizemore WA, Charlton JE. Medication management in patients with chronic non-malignant pain: a review of the use of a drug withdrawal protocol. Pain 1986; 26: 153–65

  50. 50.

    Finlayson RD, Maruta T, Morse BR. Substance dependence and chronic pain: profile of 50 patients treated in an alcohol and drug dependence unit. Pain 1986; 26: 167–74

  51. 51.

    Finlayson RD, Maruta T, Morse BR, et al. Substance dependence and chronic pain: experience with treatment and follow-up results. Pain 1986; 26: 175–80

  52. 52.

    Maruta T. Prescription drug-induced organic brain syndrome. Am J Psychiatry 1978; 135: 376–7

  53. 53.

    Maruta T, Swanson DW, Finlayson RE. Drug abuse and dependency in patients with chronic pain. Mayo Clin Proc 1979; 54: 241–4

  54. 54.

    Maruta T, Swanson DW. Problems with the use of oxycodone compound in patients with chronic pain. Pain 1981; 11: 389–96

  55. 55.

    McNairy SL, Maruta T, Ivnik RJ, et al. Prescription medication dependence and neuropsychologic function. Pain 1984; 18: 169–77

  56. 56.

    Ready LB, Sarkis E, Turner JA. Self-reported vs actual use of medications in chronic pain patients. Pain 1982; 12: 285–94

  57. 57.

    Turner JA, Calsyn DA, Fordyce WE, et al. Drug utilization pattern in chronic pain patients. Pain 1982; 12: 357–63

  58. 58.

    Fishbain DA, Rosomoff HL, Rosomoff RS. Drug abuse, dependence, and addiction in chronic pain patients. Clin J Pain 1992; 8: 77–85

  59. 59.

    Gardner-Nix JS. Oral methadone for managing chronic nonmalignant pain. J Pain Symptom Manage 1996; 11: 321–8

  60. 60.

    Tennant FS, Uelman GF. Narcotic maintenance for chronic pain: medical and legal guidelines. Postgrad Med 1983; 73: 81–94

  61. 61.

    Taub A. Opioid analgesics in the treatment of chronic intractable pain of non-neoplastic origin. In: Kitahata LM, Collins D, editors. Narcotic analgesics in anesthesiology. Baltimore (MD): Williams & Wilkins, 1982: 199

  62. 62.

    Macaluso C, Weinberg D, Foley KM. Opioid abuse and misuse in a cancer pain population [abstract]. J Pain Symptom 1988; 3: S24

  63. 63.

    Gonzales GR, Coyle N. Treatment of cancer pain in a former opioid abuser: fears of the patient and staff and their influence on care. J Pain Symptom Manage 1992; 7: 246–9

  64. 64.

    Dunbar SA, Katz NP. Chronic opioid therapy for nonmalignant pain in patients with a history of substance abuse: report of 20 cases. J Pain Symptom Manage 1996; 11: 163–71

  65. 65.

    Kaplan R, Slywka J, Slagle S, et al. A titrated analgesic regimen comparing substance users and non-users with AIDS-related pain. J Pain Symptom Manage 2000; 19: 265–71

  66. 66.

    Passik SD, Portenoy RK. Substance abuse issues in palliative care. In: Berger A, Portenoy RK, Weissman DE, editors. Principles and practice of supportive oncology. Philadephia (PA): Lippincott Raven Publishers, 1998: 513–30

  67. 67.

    Lundberg JC, Passik SD. Alcohol and cancer: a review for psycho-oncologists. Psychooncology 1997; 6: 253–66

  68. 68.

    Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA 1990; 264: 2511–8

  69. 69.

    Penick E, Powell B, Nickel E, et al. Comorbidity of lifetime psychiatric disorders among male alcoholics. Alcohol Clin Exp Res 1994; 18: 1289–93

  70. 70.

    Katz N, Fanciullo G. Role of urine toxicology testing in the management of chronic opioid therapy. Clin J Pain 2002; 18Suppl. 4: S76–82

  71. 71.

    Passik S, Schreiber J, Kirsh KL, et al. A chart review of the ordering and documentation of urine toxicology screens in a cancer center: do they influence patient management? J Pain Symptom Manage 2000; 19: 40–4

  72. 72.

    Ripamonti C, Groff L, Brunelli D, et al. Switching from morphine to oral methadone in treating cancer pain: what is the equianalgesic dose ratio? J Clin Oncol 1998; 16: 3216–21

  73. 73.

    Mercadante S, Sapio R, Serretta M, et al. Patient-controlled analgesia with oral methadone in cancer pain: preliminary report. Ann Oncol 1996; 7: 613–7

  74. 74.

    Carrol E, Fine E, Ruff R, et al. A four-drug pain regimen for head and neck cancers. Laryngoscope 1994; 104: 694–700

  75. 75.

    Lawlor P, Turner K, Hanson J, et al. Dose ratio between morphine and methadone in patients with cancer pain: a retrospective study. Cancer 1998; 82: 1167–73

  76. 76.

    Overview: current treatment realities and future trends. In: Parrino MW. State treatment guidelines. Treatment Improvement Protocol (TIP). Series 1. Rockville (MD): US Department of Health and Human Services, Center for Substance Abuse Treatment, 1993: 1–9. DHHS Publication No. (SMA) 93–1991

  77. 77.

    Zweben JE, Payte JT. Methadone maintenance in the treatment of opioid dependence: a current perspective. West J Med 1990; 152: 588–99

  78. 78.

    Handelsman L, Stein JA, Bernstein DP, et al. A latent variable analysis of coexisting emotional deficits in substance abusers: alexithymia, hostility, and PTSD. Addict Behav 2000; 25(3): 423–8

  79. 79.

    Bruera E, Moyano J, Seifert L, et al. The frequency of alcoholism among patients with pain due to terminal cancer. J Pain Symptom Manage 1995; 10(8): 599-603

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Correspondence to Dr Steven D. Passik.

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Passik, S.D., Kirsh, K.L. Opioid Therapy in Patients with a History of Substance Abuse. CNS Drugs 18, 13–25 (2004).

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  • Cancer Pain
  • Physical Dependence
  • Borderline Personality Disorder
  • Opioid Therapy
  • Substance Abuse Problem