Pseudo-addiction in cancer patients and rapid-release fentanyl for breakthrough pain: An increasingly common concern

Amezcua, Víctor; Doello, Kevin; González-Callejas, Desirée

doi:10.1016/j.medcli.2020.07.024

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Similarly, rapid-release opioids (RRO) are used as rescue for breakthrough pain crises. Increased exposure to the drug potentially means increased abuse of those opioids (if correctly prescribed), non-medical use of prescription drugs, or if they meet specific criteria, a prescription drug use disorder.Most of the risk or legally prescribed substance abuse behaviours occur with benzodiazepines, psychostimulants and opioids. In the context of cancer, concomitant phenomena are observed, with all three pharmacological groups coexisting in the same patient for the comprehensive approach to symptoms.It is estimated that 12% of patients with long-term medically prescribed opioids misuse them. These patients have a higher rate of abuse of other substances such as marijuana, heroin and benzodiazepines and are much more likely to develop mood disorders.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> Data on prescription drug use disorders are based on DSM Edition IV, which states that 26% of long-term opioid users<a class="elsevierStyleCrossRef" href="#bib0035">2</a> fit the criteria for abuse and dependence. Other studies in the same vein are somewhat more conservative, but addiction to prescription opiates is a reality, ranging in prevalence from 3 to 29 per cent. There are no data at the moment on RRO users.However, the emergence of RRO on the market has revealed previously unseen patterns of behaviour. The concept of pseudo-addiction emerges in our daily life. It cannot be considered as a strict addiction, since it does not meet all the criteria for alterations in the use of opioids in the DSM-V (previously concepts of abuse or dependence), but it is undoubtedly an aberrant behaviour associated with opioids,<a class="elsevierStyleCrossRef" href="#bib0040">3</a> where changes in behaviour similar to those of patients with true addiction, but secondary to inadequate treatment of the pain base, can be observed.In our registry, we noted that aberrant behaviour patterns associated with RRO appear in cancer patients, and it is evident that some of our patients take other RRO drugs or other presentations obtained illegally or by prescription, request “loans” of medications from family members or neighbours, request prescriptions in advance or even make frequent visits to different doctors to obtain more prescriptions (“doctor shopping”).In susceptible patients with an addictive phenotype (neurobiological and clinical basis, where a higher excitation of the reward system prevails) where a consultation cannot be made as often as desirable due to the overload of care, this dangerous phenomenon of pseudo-addiction can occur. It can promote complications such as therapeutic noncompliance, intestinal obstruction, amnesia syndrome, opioid-associated hyperalgesia, domestic or motor vehicle accidents, overdose and even early death. It is also associated with an increase in consultations, admissions and costs. It is therefore a not insignificant public health problem that should be detected.<a class="elsevierStyleCrossRef" href="#bib0045">4</a>There is literature on pseudo-addiction in the context of modified-release opioids. Pseudo-addiction associated with RRO is not adequately described. The main self-administered questionnaires (opioid risk tool, ORT, Screener and Opioid Assessment for Patient with Pain and Current Opioid Misuse Measure to Monitor)<a class="elsevierStyleCrossRef" href="#bib0050">5</a> are limited in the context of modified-release opioids and are not validated in the context of ROLs or cancer patients.It would be interesting to form a multidisciplinary group that allow the design of tools and questionnaires for early detection and risk assessment in this context that would facilitate the physician to create risk management strategies in the misuse and abuse of opioids. They would allow for a better selection of the most convenient opioid according to its addictive potential, treatment methods, deshabituation and detoxification of these patients, a better multidisciplinary follow-up and in short, to address this public health problem and to personalise the therapeutic options in patients with aberrant behaviour associated with opioids.Conflict of interestsNone to declare." 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