Radio personality Rush Limbaugh, actor Matthew Perry, actor Colin Farrell, and National Football League (NFL) quarterback Brett Favre have more than celebrity status in common. Each of them has struggled with prescription medication addiction. In 2003, Limbaugh was reported to be under investigation for illegal activities surrounding prescription medication abuse.² One week after the story broke, he acknowledged its truth during his nationally broadcast show, and stated that he would enter a 30-day in-patient treatment program immediately following his show that day.2 Mr. Limbaugh asserted that he became addicted to prescription narcotic analgesic medications subsequent to severe back pain and failed surgery, and was taking 8 hydrocodone per day.² In 2005, Colin Farrell checked himself into a treatment center for addiction to prescription medications following a back injury.³ Matthew Perry struggled with an addiction to the prescription narcotic medication Vicodin.⁴ Finally, Brett Favre became addicted to prescription opiate analgesics following a car accident in 1990 and multiple sports injuries. He participated in the NFL’s substance abuse program.⁵
How do compliant medical patients seeking treatment for complex pain problems become identified narcotic addicts? Why do some physicians inappropriately prescribe narcotics? How does a doctor-patient relationship deteriorate to the point where both the patient and physician become dissatisfied and suspicious of each other?
The aim of this paper is two-fold: 1) to educate all groups and individuals impacted or impressed upon by opioids; and 2) to provide an evaluation of tools for detection of potential misuse.
In Part One, we will begin with a history of opiates, followed by a brief discussion of the difference between acute and chronic pain, and the uses of opiates in the management of pain. We will then describe, at length, the complex interactions among the ‘players’, namely, patients, doctors, law enforcement, regulatory agencies, manufacturers, insurance carriers, the media, family, and pharmacists (see Figure 1). Subsequently, we will describe types of abuse/misuse, including addiction, dependence, tolerance, and iatrogenic addiction and pseudoaddiction.
In Part Two, we will review the methods for monitoring substance use and assessing/predicting the potential for misuse, including narcotic agreements, objective laboratory tests (e.g., urinalysis), history and physical examination, and self-report questionnaires.
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