We thank Dr Wolter for his comments However, we remain unconvinced that the probability of developing an addiction disorder de novo is extremely low in people without a history of addiction. Especially in the context of rapid-release opioids, the literature increasingly contains reports of developing medication misuse leading all the way to opioid dependency, even in patients with no apparent history of addiction (1). Whether screening instruments offer any solution to this problem is doubtful. Particular cause for concern comes from a retrospective analysis of five studies in which buccal fentanyl was given to non-cancer patients for breakthrough pain (2). The focus of the data analysis was to determine the frequency of so called aberrant drug-related behavior. “Aberrant behavior” as an indicator of loss of control and misuse and dependency was defined, among others, as unpermitted passing on of the prescribed opioids to third parties, forged prescriptions, and repeated, unauthorized dosage increases. Although patients with a history of drug misuse where excluded from these studies, 11% of included and highly selected patients developed behaviors that were classified as aberrant drug behavior.
This raises the fundamental question which factors increase the probability of receiving opioid treatment. Turk and Okifuji showed that only non-verbal pain behavior and not objectifiable factors, such as pain intensity or physical findings, affected the probability of being given an opioid (3).
On the background of increasing numbers of opioid prescriptions and the intensified treatment especially for non-cancer-related pain we should be aware of these context and potential risks (4).
On behalf of the authors:
Prof. Dr. med. Rainer Sabatowski
Universitätsklinikum „Carl Gustav Carus“
Technische Universität Dresden
Conflict of interest statement
Professor Sabatowski has acted as consultant for Cephalon and Janssen-Cilag. He has received fees for the preparation of specialist training courses from MSD and Grünenthal. The University Pain Center Dresden has received payments from Grünenthal, Astellas, and Allergan for conducting commissioned clinical studies.
|1.||Scharnagel R, Kaiser U, Schütze A, Heineck R, Gossrau G, Sabatowski R: Chronic non-cancer-related pain: Long-term treatment with rapid-release and short-acting opioids in the context of misuse and dependency. Schmerz 2013; 27: 7–19 CrossRef MEDLINE|
|2.||Passik SD, Messina J, Golsorkhi A, Fang X: Aberrant drug-related behavior oberserved during clinical studies involving patients taking chronic ppioid therapy for persistent pain and Fentanyl buccal tablet for breakthrough pain. J Pain Symptom Manage 2011; 41: 116–25 CrossRef MEDLINE|
|3.||Turk DC, Okifuji A: What factors affect physicians' decisions to prescribe opioids for chronic noncancer pain patients? Clin J Pain 1997; 13: 330–6 CrossRef MEDLINE|
|4.||Schubert I, Ihle P, Sabatowski R: Increase in opiate prescription in Germany between 2000 and 2010—a study based on insurance data. Dtsch Arztebl Int 2013; 110(4): 45–51. VOLLTEXT|