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Vol. LIX, No. 7
April 6, 2007

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The Addiction Connection
NIDA Conference Looks at Pain, Opioid Use

On the front page...

Debating the necessity of opioids and their risk of addiction is nothing new. People decried the problems of opioid addiction as early as 300 B.C., according to Dr. Nathaniel Katz, director of the Program in Opioid Risk Management at Tufts Health Care Institute. Throughout history, he said, societal views of opioids have fluctuated dramatically between two “dogmas”: they are panaceas, and the opposite—the addiction risk is too great to prescribe them.

“What will be the next dogma?” Katz asked, suggesting that we should instead replace dogma with science, “so we can anchor the pendulum of opinion firmly in the middle and avoid these swings in opinion that harm so many patients.”


  VLTP recipient Karen Adams with photo of son Richard Worsley III—“We call him RJ.”  
  VLTP recipient Karen Adams with photo of son Richard Worsley III—“We call him RJ.”  
His lecture was part of a recent 2-day conference at NIH sponsored by NIDA and the American Medical Association. With more than 500 attendees and close to 30 speakers, the meeting, “Pain, Opioids and Addiction: An Urgent Problem for Doctors and Patients,” served as a new kind of discussion. For the first time at NIH, the field of pain management became a big part of the opioid-addiction debate.

Dr. Nora Volkow, director of NIDA, said the conference came as a result of recent research showing a growing problem of prescription painkiller abuse. She cited the NIDA-funded 2006 Monitoring the Future Survey revealing that one in 10 high school seniors used the painkiller Vicodin for non-medical purposes in the past year. At the same time, much has been learned in recent years about the neurobiology of opioids, the epidemiology of pain and addiction, how genetic factors may play a role and potential methods of treatment for the future. Now, Volkow said, we need to determine “how to use this knowledge to minimize severe pain, while also reducing the dangers of addiction.”

The conference began with a series of lectures outlining how opioids work and how pain is modulated in the brain. “We have learned a great deal about pain and how to effectively manage pain,” said Dr. Mary Jeanne Kreek, a neurobiology researcher at Rockefeller University, adding that there’s “always more to learn.” She detailed the importance of opioid receptors in the brain, which are the basis for both pain relief and addiction. She discussed the history of research in this area and how we’ve learned that the factors contributing to addiction can be environmental, genetic and drug-induced.

Dr. Nathaniel Katz
Dr. Nathaniel Katz (above) and Dr. Kathleen Foley (below) offered expert perspective on modern pain management.
Dr. Kathleen Foley

Others spoke about specific laboratory research conducted on opiate analgesics and whether we can see the connections between pain and addiction using imaging techniques. But it was the next panel that put the conference in historical and societal perspective. Dr. David Musto, professor of child psychiatry and the history of medicine at Yale University, gave an overview of the history of addiction in the United States. He discussed shifts in attitude on opioid treatment, ranging from the 19th century, when opioids were considered “God’s own medicine,” to the first half of the 20th century, when fear of addiction led to poor pain control. He noted that while opioids have become more popular in recent years, we are currently turning back into a “decline phase” similar to that of the 1920s and 1930s, when a trend against using analgesics was “part of a larger antagonism toward drug use.” It is vital to understand this trend and to include within anti-drug campaigns information on legitimate medical uses of opioids, Musto said. “Without this effort, the broad anti-drug movement in the United States may again unintentionally impede humane treatment to those in pain and distress.”

This introduced a larger discussion of what has been learned in recent years about the epidemiology of pain. Dr. Kathleen Foley, an expert in cancer pain and a neurologist in the Pain and Palliative Care Service at Memorial Sloan-Kettering Cancer Center, said she was at first “shocked” by the purpose of the meeting. “It suggested that the urgent problem was chronic pain patients becoming addicts, for which there is no evidence,” she explained. “To me, the urgent problem is the extraordinary lack of effective treatments we have for patients with pain.” But the conference provided an opportunity to raise important questions, she said. These include: Who is involved with prescription drug abuse? And what are the sources of the drugs that are abused? She also looked at recent data highlighting the effects of misinformation about the sources of the prescription drugs that are abused and gave a history of chronic cancer pain research, stressing the many areas of study that need more attention.

On the second day of the conference, a group of clinicians related all of this data to the issue of doctor-patient interaction, where “the rubber meets the road,” said Dr. Steven Passik, associate attending psychologist at MSKCC and assistant professor at Weill Medical College, Cornell University. His interests lie in using what we know about aberrant drug-taking behaviors to help doctors understand how to provide better treatment.

There are behaviors that are more obvious predictors of drug abuse, however they are rare, opaque to clinicians and usually not elicited in self-report, he said. There are also less-predictive behaviors—like drug hoarding and unsanctioned dose escalation—that are common and sometimes reported by patients, but are harder to interpret as to whether they indicate abuse, diversion or simply untreated pain. When Passik and his fellow researchers asked a group of physicians to rank these behaviors in order of importance, there was almost no consensus. In another survey, they found that 45 percent of a group of patients taking opioids for at least 6 months showed some aberrant behavior.

Therefore, he said, it’s clear physicians are “going to be confronted with behavior that [they are] going to have to sort out…and react to it and manage it.” He also looked into the drivers of these behaviors and described several screening tools that may help in determining whether or not a patient should start opioid treatment.

This information is “very encouraging,” said Dr. Howard Fields, professor of neurology and physiology and director of the Wheeler Center for the Neurobiology of Addiction at the University of California, San Francisco, whose talk concluded the conference.

But, he said, this is just the start. In the future, “perhaps we’ll come up with an addiction or pain treatment gene chip” that will help determine who is predisposed to becoming an opioid abuser. It may become possible to use brain imaging to understand better the patterns of activity when people complain of pain. He also said the “big frontier” is pharmacogenetics. There could eventually be genetic screening to determine which opioids or combinations of drugs would be ideal for a specific patient.

Finally, he said, there remains hope that in the future we will develop an ideal analgesic that’s “completely safe and totally effective,” that works on all types of pain and that’s non-addicting. When this happens, people in pain will receive appropriate treatment without any risk of addiction. And then, Fields added, smiling, “we won’t have to have these conferences anymore.” NIH Record Icon

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