Dual Diagnosis

As a Psychiatrist, Addiction Psychiatrist, Forensic Psychiatrist and Attorney, I gained a comprehensive perspective of the

problems associated with opioid prescription medications. As the editor and author of the issue, I attempted to provide

clinical and research experience and a comprehensive review of the available medical and scientifi c literature to the questions

regarding effi cacy for prescribing opioid medications for chronic pain. And why is the current policy to prescribe these

medications on demand fueled by patients? Th is issue of Psychiatric Annals on prescription opioid medications answers the

following questions: Why are opioid medications prescribed in large quantities and high frequency when there is little or

no proven effi cacy for their therapeutic value? Why are opioids the most commonly prescribed medication in the United

States when their adverse consequences continue to grow and mount? Why does the medical profession continue to prescribe

opioid medications that result in increased pain, psychiatric and medical disability, and even death? When the evidence

is reviewed, there is minimal support for long-term prescribing of opioid medications. An extensive review of over 2,000

publications did not fi nd evidence to justify opioid medication for chronic pain. In addition, there were few articles that

researched addiction despite opioid medications’ highly addicting pharmacologic properties. In fact, opioid addiction explains

why doctors prescribe and patients consume opioids continuously with substantial risks of psychiatric and medical adverse

consequences—and without benefi t. Th e Diagnostic and Statistical Manual of Mental Disorders, fi ft h edition (DSM-5) provides

for a diagnostic scheme for the frequent occurrence of substance or opioid-induced psychiatric disorders titled “Substance/

Medication-Induced Depressive Disorder and Substance/Med-ication-Induced Anxiety Disorder.” In DSM-5 the exclusionary

criteria require accounting for psychiatric eff ects of opioid medications, such as depression and anxiety and withdrawal, before

making diagnoses of depressive and anxiety disorders. Th e effi cacy for prescribing opioid medications for chronic pain is not

only limited by their highly addicting nature, but also by a paradoxical response—opioid-induced hyperalgesia. Surprisingly,

opioids induce pain through increased pain sensitivity locally at the site of the lesions or diff usively at non-pathologic sites.

Th us, effi cacy is severely limited by mounting subjective pain induced by opioids. Th e engine that drives continued opioid use

is, according to DSM-5, “Addictive and Opioid Use Disorders.” Opioid medications are scheduled medications defi ned by the

Controlled Substance Laws as highly dangerous and addicting. Th e commonly prescribed opioid medications are schedule II,

which Dr. Th omas Frieden, Director of the Centers for Disease Control and Prevention, recommends prescribing for no longer

than 3 days except in extreme, justifi ed cases due to their highly addicting nature.