Implications of hedonic effects of opioids in clinical practice Reply

Letter to Editor: I enjoyed the recent article on hedonic and calming effects of opioids, opioid craving, and misuse.6 This study carefully evaluated a large number of factors which might relate to patients' daily choices as to how they use prescribed medications. Since the authors describe a lack of prior research on the impact of hedonic effects on opioid misuse in the clinical setting, I respectfully present several pertinent publications which were difficult to find in my own literature search. They have both consistent and somewhat differing results from the current study. In addition, I would like to provide a rationale to expand on clinical implications proposed by the authors. Bieber et al. evaluated the subjective effects of opioids experienced by study participants at the time of their very first exposure to prescription opioids.1 This study compared a group on long-term opioid therapy at a pain center with a group whose initial exposure to opioids was for chronic pain but who were currently receiving treatment of opioid addiction. The Addiction Center Research Inventory7,8 was completed by both groups. The Addiction Center Research Inventory scores were much higher, indicating more euphoric effects from opioids, in those who later became addicted to opioids. Yet the group that was not addicted also reported frequently experiencing hedonic effects of opioids. 30% recalled “I was full of energy,” 25% noted “things around me seemed more pleasing than usual,” 35% “felt more clear headed than dreamy,” and 25% recalled “feeling more excited than dreamy.” The Kaiser Family Foundation performed a phone survey of recipients of chronic opioid prescriptions. This was self-published on the website of the Kaiser Family Foundation in December of 2016.2 20% of survey respondents reported that a major reason for using prescribed opioids was “for fun or to get high,” 14% “to deal with day to day stress,” and 10% “to relax or relieve tension.” An additional 14%, 8%, and 3%, respectively, reported that it was a minor reason to use prescribed opioids for these purposes. In a phone survey of retired National Football League players,4 participants were asked if they used opioid medications for any of the following purposes: to function; to change mood, be happy, or get high; to relax, calm down or relieve stress; to sleep; or for pain. Roughly 25% exposed to prescribed pain medications during their playing career were currently prescribed opioids. Of those, 45% disclosed current misuse of opioids. 35% of those currently misusing opioids reported that during their playing careers they used opioids to relax or relieve stress, whereas 22% reported opioid use to improve mood. These articles seem to have substantial agreement with Frimerman et al., in that all show a very high rate of hedonic effects of prescribed opioids. However, patients in the 2 phone surveys reported a wider variety of hedonic effects than were evaluated in this study and a higher rate of opioid misuse. The authors suggest 2 important clinical implications of these data: to routinely discuss the possibility of hedonic effects with patients and cognitive behavioral or mindfulness interventions for those patients who seek the pleasurable or calming effects of opioids. These seem to be very reasonable responses to their findings and the impact of misuse on clinical outcomes. I propose another clinical implication: The information that is discussed here, and in the extensive body of research cited in their references, is not already widely shared in the locations where it would seem most likely to be seen by the medical community: in opioid management guidelines, standardized informed consent documents, and medication management agreements.3,5,9 By contrast, the risk of addiction is already covered in these documents. Similarly, ordinary risks common to opioids and many other medications, such as nausea, sedation, constipation, and lack of sufficient therapeutic effects, are also already discussed. Thus, there would seem to be an opportunity for substantially more complete discussions with our patients. For any other medication, to treat any other condition, it would be expected to include such frequent and important side effects in a reasonably thorough informed consent process. Thus, these effects of opioids should be included in each of informed consent documents, medication management agreements, and pain management guidelines. Conflict of interest statement The author has no conflicts of interest to declare.