It is recognized in the bleeding disorders community that opioid medications can be a helpful addition to the treatment plan for patients experiencing refractory acute pain, as well as for those with long-standing chronic pain  resulting from joint disease. Opioids as a class of drugs are used for many types of pain. According to the Centers for Disease Control and Prevention in 2012, healthcare providers wrote 259 million prescriptions for opioids, a number that had actually leveled off after decades of escalation. This leveling off is likely due to increasing awareness of opioid abuse, underscored by the fact that each day 46 people die from an overdose of prescription painkillers in the US (CDC). Clearly, despite being a highly effective medication class, awareness of the potential for harm needs to be discussed.
Opioid medications work by attaching to opioid receptors in the brain, reducing the perception of pain. A subsequent effect is the release of dopamine, which is well known to be linked to feelings of pleasure. This connection is likely a major reason that opioids as a class have a high potential for abuse. To understand the nuances of opioid abuse, it is critical to understand the differences between tolerance, physical dependence,
and addiction.
Opioids have a distinct place in the treatment of patients with hemophilia who are experiencing severe acute pain or chronic pain and are unresponsive to non-steroidal anti-inflammatory drugs (NSAIDs). Because of the biochemical processes that take place when opioids are administered, varying degrees of tolerance and physical dependence can be expected over time with chronic exposure. Physicians, particularly pain experts, are well versed in navigating these effects safely with patients who require opioid therapy, however this requires that the patient and the prescribing physician develop a plan for appropriate opioid use that is closely followed. Certain patients are at a much higher risk of developing addiction and physicians should be aware of these risk factors. Patients displaying addictive tendencies should undergo a multidisciplinary evaluation with their primary hemophilia physician, a mental health expert, and an addiction specialist.
Tolerance
• A need for a greater amount of a drug to maintain the therapeutic effect with the loss of efficacy over time.
Dependence (Physical)
• Neurochemical changes in the body require continued use of the substance. Withdrawal syndrome occurs if the medication is discontinued, the dose is substantially decreased, or an antagonist is administered.
Addiction (Psychological Dependence)
• A psychiatric disorder characterized by continued compulsive use of a substance despite harm to the patient. Effects from the use of the medication are desired and reinforce continued use.
Learn more by reading the Winter 2015 edition of Dateline: Federation. This edition includes perspectives of this issue by 5 different community members of the bleeding disorders community.
If you or a loved one need help, the Substance Abuse and Mental Health Administration’s (SAMHSA) National Helpline  is a confidential, free, 24-hour-a-day, 365-day-a-year, information service, in English and Spanish, for individuals and family members facing mental health and/or substance use disorders.
Erika Mora is a Clinical Pharmacist Specialist practicing in inpatient hematology and oncology at the University of Michigan CS Mott Children’s Hospital in Ann Arbor, Michigan. Mora graduated with her PharmD degree from the University of Georgia and completed post-graduate residencies at Northeast Georgia Health System and Mayo Clinic. She has been in her current position for six years.
