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Three Part Question

In [patients with an acute porphyria] is [there a greater incidence of opiate abuse] than [in the general population]?

Clinical Scenario

A 43 year old male presents to the ED with severe abdominal pain. He tells you suffers from acute intermittent porphyria, he is having an acute attack and requires IV pethidine. Your colleague takes you aside and advises you to not to give him any opiate analgesia as he suspects the patient is an opiate abuser. You wonder if there is a higher incidence of opiate abuse in patients with an acute porphyria.

Search Strategy

Medline 1966 to 06/06 via the Ovid Interface
[exp substance abuse/ or substance abuse.mp. or exp substance related disorders/ or opiate abuse.mp. or opiate addiction.mp. or narcotic abuse.mp. or narcotic addiction.mp. or opiate.mp.] AND [exp porphyrias/ or porphyrias.mp. or porphyria.mp. or AIP.mp.] LIMIT to humans
Embase 1980 to 06/06 and Cinahl 1982 to 06/06 via the Ovid interface
[exp substance abuse/ or substance abuse.mp. or exp substance related disorders/ or opiate abuse.mp. or opiate addiction.mp. or narcotic abuse.mp. or narcotic addiction.mp. or opiate.mp.] AND [exp porphyria/ or porphyrias.mp. or porphyria.mp. or AIP.mp.] LIMIT to humans and english language
Cochrane:porphyria

Search Outcome

Medline:191 results-1 relevant
Embase: 69 results-1 relevant
Cinahl:8 results-0 relevant
Cochrane:32 results-0 relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Proctor EA, McKenzie IP 1994 uk	30 year old female with AIP and opiate dependance. She was admitted to a psychiatric hospital with depression after the death of a child. She suffered from episodes of abdominal pain on the ward for which she was treated with morphine sulphate tablets but her demands for morphine increasingly became more aggressive and there was a discrepancy between pain and morphine requests. She admitted regular morphine consumption over the past year, following the death of her baby, obtaining morphine using repeat prescriptions from her GP surgery. She did not require detoxification and following discharge she attended a bereavement group and no further opiate use was reported in the 18 month follow up.	Case study. Level 3.			Case report.

Comment(s)

There is no evidence to suggest that opiate addiction is more prevalent in the patients with an acute porphyria than in the general population although opiate addiction is a risk in all conditions requiring narcotic analgesia [1]. If opiate addiction is suspected, a detailed drug history should be obtained (as in all cases of suspected drug abuse), but only after the symptoms of the attack have been dealt with. Pain control in acute porphyria is of utmost importance therefore adequate pain relief should be given in those suffering an acute attack. Education of medical staff dealing with patients presenting with an acute attack is important.

Clinical Bottom Line

There is no evidence to suggest that patients with acute porphyria have an increased incidence of opiate addiction. Adequate pain relief should always be given in those suffering from an acute attack.

References

1. Proctor EA, McKenzie IP Opiate dependance in acute intermittent porphyria Irish Journal of Psycological Medicine 1994;11(3):133-134
2. Tarczynska NS, Kostrzewska E Social problems of porphyria Polski Merkuriusz Lekarski 1998;4:147-9